Beruflich Dokumente
Kultur Dokumente
does not necessarily represent the decisions or the stated policy of the World Health Organization
894
Report of a
WHO Consultation
3.Cost of illness
Contents
1.
Introduction
1.1
1 .2
3.
3
4
5
6
6
7
8
8
8
9
9
11
11
11
12
12
13
16
16
17
17
20
20
21
21
21
22
23
23
24
24
24
24
25
25
26
27
27
29
30
31
34
iii
Part 11
4.
5.
iv
38
39
39
40
40
42
43
44
46
46
48
49
50
51
51
53
54
54
55
55
56
57
57
57
58
58
59
59
59
60
60
60
69
69
69
70
70
70
70
71
71
71
72
72
72
73
6.
74
74
75
78
78
79
80
80
81
83
83
83
86
88
88
89
89
Part Ill
7.
Part IV
8.
90
91
97
100
101
101
102
102
105
105
107
108
108
112
118
118
124
126
129
133
134
137
139
142
142
153
154
154
8.2
9.
vi
156
156
157
158
160
162
163
164
164
166
167
167
170
170
174
174
175
176
178
179
179
179
180
180
181
181
182
183
184
184
187
189
190
190
192
192
194
10.
Part V
11.
197
197
198
198
200
200
201
203
203
204
205
206
208
208
209
209
210
210
211
211
213
215
217
221
223
223
224
224
226
228
231
239
240
240
241
241
243
245
24 7
Acknowledgements
251
Annex
Criteria for evaluating commercial institutions involved in weight loss
253
vii
* Unable to attend: Professor M.J. Gibney, Department of Clinical Medicine, Trinity Centre
for Health Sciences, St James's Hospital, Dublin, Ireland; ProfessorS. Rossner, Health
Behaviour Research, Obesity Unit, Karolinska Hospital, Stockholm, Sweden; Or F.
Shaheen, Director, Nutrition Institute, Cairo, Egypt.
viii
Invited but unable to send a representative: United Nations Children's Fund (UNICEF),
New York, NY, USA; United Nations University (UNU), Tokyo, Japan.
ix
Abbreviations
The following abbreviations are used in this report:
AIHW
ALCO
BMI
BMR
CHD
CHNS
CHO
CINDI
CVD
DALY
DEXA
ENDEF
EPI
EPOC
FDA
HCG
HDL
HMR
HPA
IGT
INTERHEALTH
INTERSALT
IOTF
LDL
LDL-apoB
LMS
LPL
MONICA
NCD
NCHS
NEFA
NHANES
NHES
NHMRC
NIDDM
NNS Ill
OA
PAF
PAL
PNSN
POP
REDP
RMR
RR
SBW
SHBG
SOS
SSRI
STD
TEF
TOPS
VLCD
WHR
xii
1.
Introduction
The WHO Consultation on Obesity met in Geneva from 3 to 5 June
1997. Dr F.S. Antezana, Deputy-Director General ad interim, opened
the meeting on behalf of the Director-General. This consultation was
the culmination of a two-year preparatory process, involving more
than 100 experts worldwide, undertaken in close collaboration with
the Rowett Research Institute (a WHO collaborating centre for nutrition) in Aberdeen, Scotland, and the International Obesity Task
Force (IOTF) chaired by Professor Philip James, Director of the
Rowett Research Institute.
The overall aim of the Consultation was to review current epidemiological information on obesity, and draw up recommendations for
developing public health policies and programmes for improving the
prevention and management of obesity. The specific objectives of the
Consultation were:
-
1.1
The report is divided into five parts, the first four of which deal with
different aspects of the global epidemic of obesity. The final part
outlines the conclusions and recommendations of the WHO Consultation on Obesity.
Part I examines the definition and classification of obesity, and sets
out the most recent data on the global prevalence and secular trends
in all regions of the world. Defining and identifying the extent of the
problem of obesity is a critical first step in a coherent approach to its
prevention and management.
Part 11 covers the true costs of obesity in terms of physical and mental
ill health, and the human and financial resources diverted to deal with
the problem. The amount of suffering that obesity causes, and the
money spent by health agencies in dealing with it, are enormous and
reinforce the need for urgent action.
Part Ill examines what is known about this complex, multifactorial
disease and identifies the major factors implicated in its development.
Most of the information about risk factors for weight gain and obesity
comes from studies in developed countries because developing countries have only recently seen a rise in chronic diseases and therefore
have little experience in carrying out research in this area. Examination of the factors involved in weight gain and obesity in developed
countries, however, is of worldwide relevance in predicting the future
impact in countries in the early stages of frequently dramatic socioeconomic change and provides a unique opportunity for taking preventive action. It is also important that these factors should be taken
into account in any coordinated strategy designed to tackle the problem of obesity.
Part IV takes account of the matters considered in the preceding
three parts and presents the foundations of a comprehensive strategy
for the prevention and management of obesity through health care
services and public health policy. Policy-makers, health professionals
and the community at large need to join forces in tackling this major
global public health problem.
Part V outlines the final conclusions and recommendations of the
WHO Consultation on Obesity. Priority areas for further research are
identified, and recommendations on strategies and actions for the
effective prevention and management of the global epidemic of
obesity are made.
3
1.2
Obesity is a complex and incompletely understood disease. This report highlights key issues central to the development of a coherent
strategy for the effective prevention and management of obesity on a
worldwide basis. A number of important themes have dictated the
content and style of the report, including the following:
Obesity is a serious disease, but its development is not inevitable. It
is largely preventable through lifestyle changes.
The health risks of excessive body fat are associated with a relatively small increase in body weight, not only with marked obesity.
Effective management of obesity cannot be separated from
prevention.
Obesity is not just an individual problem. It is a population problem
and should be tackled as such. Effective prevention and management of obesity will require an integrated approach, involving actions in all sectors of society.
Obesity is a chronic disease that requires long-term strategies for its
effective prevention and management.
Obesity affects all age groups. The effective prevention of adult
obesity will require the prevention and management of childhood
obesity.
Obesity is a global problem. Prevention and management strategies
applicable to all regions of the world should be developed.
Obesity can be seen as just one of a defined cluster of noncommunicable diseases (NCDs) now observed in both developed and developing countries. The global epidemic of obesity is a reflection of
the massive social, economic and cultural problems currently facing
developing and newly industrialized countries, as well as the ethnic
minorities and the disadvantaged in developed countries.
Examination of the factors involved in weight gain and obesity in
developed countries is crucial for predictions about the future impact in countries in the early stages of frequently dramatic socioeconomic change and provides a unique opportunity for taking
preventive action.
In countries with developing economies, the problem of obesity is
emerging at a time when undernutrition remains a significant problem. Strategies that take account of both these important nutritional problems will need to be developed, particularly when dealing with children whose growth may be stunted.
4
PART I
2.
2.1
Introduction
Obesity is often defined simply as a condition of abnormal or excessive fat accumulation in adipose tissue, to the extent that health may
be impaired (1). The underlying disease is the undesirable positive
energy balance and weight gain. However, obese individuals differ
not only in the amount of excess fat that they store, but also in the
regional distribution of that fat within the body. The distribution of
fat induced by weight gain affects the risks associated with obesity,
and the kinds of disease that result. Indeed, excess abdominal fat is as
great a risk factor for disease as is excess body fat per se. It is useful,
therefore, to be able to distinguish between those at increased risk as
a result of "abdominal fat distribution", or "android obesity" as it is
often known, from those with the less serious "gynoid" fat distribution, in which fat is more evenly and peripherally distributed around
the body.
Classifying obesity during childhood or adolescence is further complicated by the fact that height is still increasing and body composition
is continually changing. Furthermore, there are substantial international differences in the age of onset of puberty and in the differential
interindividual rates of fat accumulation.
This section outlines the most appropriate methods for: (a) classifying
overweight and obesity in adults; and (b) identifying abdominal fat
distribution. It also briefly discusses the use of additional tools for use
in the more detailed characterization of obese individuals. The final
section outlines the current lack of consistency and agreement
between studies in the classification of obesity in childhood and
adolescence, and highlights the need for a globally standardized
classification system.
The key issues covered include the following:
Obesity can be defined simply as the disease in which excess body
fat has accumulated to such an extent that health may be adversely
affected. However, the amount of excess fat, its distribution within
the body, and the associated health consequences vary considerably between obese individuals.
The graded classification of overweight and obesity: (a) permits
meaningful comparisons of weight status within and between populations; (b) makes it possible to identify individuals and groups at
increased risk of morbidity and mortality; (c) enables priorities to
be identified for intervention at individual and community levels;
and (d) provides a firm basis for the evaluation of interventions.
6
Body mass index (BMI) (see section 2.3) provides the most useful,
albeit crude, population-level measure of obesity. It can be used to
estimate the prevalence of obesity within a population and the risks
associated with it. However, BMI does not account for the wide
variation in body fat distribution, and may not correspond to the
same degree of fatness or associated health risk in different individuals and populations.
Obese individuals with excess fat in the intra-abdominal depots are
at particular risk of the adverse health consequences of obesity.
Therefore, measurement of waist circumference provides a simple
and practical method of identifying overweight patients at increased risk of obesity-associated illness due to abdominal fat
distribution.
Ethnic populations differ in the level of risk associated with a
particular waist circumference, and a globally applicable grading
system of waist circumference has not yet been developed.
Additional tools available for the more detailed characterization of
the obese state include methods of measuring body composition
(e.g. underwater weighing), determining the anatomical distribution of body fat (e.g. magnetic resonance imaging), and measuring
energy intake (e.g. prospective dietary record) and energy expenditure (e.g. doubly labelled water). However, the cost of such techniques and the practical difficulties involved in applying them limit
their usefulness to research.
As previously mentioned, the classification of the weight status of
children and adolescents is complicated by the fact that height and
body composition are continually changing, and that such changes
often occur at different rates and times in different populations,
making simple universal indices of adiposity of little value. To date,
there has not been the same level of agreement on the classification
of obesity for children and adolescents as there is for adults.
2.2
2.3
= 22.9
Table 2.1
Classification of adults according to BMia
Classification
BMI
Risk of comorbidities
Underweight
<18.50
Normal range
Overweight:
Preobese
Obese class I
Obese class 11
Obese class Ill
a
18.50-24.99
:2:25.00
25.00-29.99
30.00-34.99
35.00-39.99
:2:40.00
Average
Increased
Moderate
Severe
Very severe
These BMI values are age-independent and the same for both sexes. However, BMI may not
correspond to the same degree of fatness in different populations due, in part, to differences
in body proportions (see section 2.3.2). The table shows a simplistic relationship between BMI
and the risk of comorbidity, which can be affected by a range of factors, including the nature
of the diet, ethnic group and activity level. The risks associated with increasing BMI are
continuous and graded and begin at a BMI above 25. The interpretation of BMI gradings in
relation to risk may differ for different populations. Both BMI and a measure of fat distribution
(waist circumference or waist: hip ratio (WHR)) are important in calculating the risk of obesity
comorbidities.
Table 2.2
Sex-specific waist circumference and risk of metabolic complications associated
with obesity in Caucasians
Risk of metabolic complications
Increased
Substantially increased
a
Women
~94
~80
~102
~88
This table is an example only. The identification of risk using waist circumference is
population-specific and will depend on levels of obesity and other risk factors for CVD and
NIDDM. This issue is currently under investigation.
The sex-specific waist circumferences given in Table 2.2 denote enhanced relative risk for a random sample from the Netherlands of
2183 men and 2698 women aged 20-59 years (23).
2.5
Table 2.3
Currently recommended characteristics for measurement in genetic studies
Characteristic of
obesity measured
Body composition
BMI; waist circumference; underwater weighing; dualenergy X-ray absorptiometry (DEXA); isotope dilution;
bioelectrical impedance; skinfold thickness
Anatomical distribution
of fat
Partitioning of nutrient
storage
Energy intake
Energy expenditure
13
The most widely used growth reference, which WHO has recommended for international use since the late 1970s (25, 26), was developed by the US National Center for Health Statistics (NCHS).
However, a WHO Expert Committee (2) has drawn attention to a
number of serious technical and biological problems with this growth
reference. WHO is therefore currently undertaking the development
of a new growth reference for infants and children from birth to 5
years. This will be based on a sample of infants and children from
different parts of the world whose caregivers follow internationally
recognized health recommendations. A similar reference will also be
required for older children and adolescents.
2.6.3 BMI-for-age reference curves
Such curves have been produced for a number of countries (6, 27-29).
However, many are imperfect either because the data are old or
because the age range is restricted. More recent BMI-for-age charts
have been developed for British, Italian and Swedish children (30-32)
using the least mean square (LMS) method of Cole (33), which adjusts BMI distribution for skewness and allows BMI in individual
subjects to be expressed as an exact centile or standard deviation
score. The use of BMI-for-age is currently being explored, in parallel
with other potential techniques, by an expert working group in order
to determine the best method of classifying overweight and obesity in
childhood. A common standard should allow the comparative evaluation of childhood obesity internationally.
References
1. Garrow JS. Obesity and related diseases. London, Churchill Livingstone,
1988:1-16.
10. Han TS et al. The influences of height and age on waist circumferences as
an index of adiposity in adults. International Journal of Obesity and Related
Metabolic Disorders, 1997, 21:83-89.
13
11. James WPT. The epidemiology of obesity. In: Chadwick DJ, Cardew GC,
eds. The origins and consequences of obesity. Chichester, Wiley, 1996:116 (Ciba Foundation Symposium 201 ).
12. Seidell JC. Are abdominal diameters abominable indicators? In: Angel A,
Bouchard C, eds. Progress in Obesity Research: 7. London, Libbey,
1995:305-308.
13. Lean MEJ, Han TS, Morrison CE. Waist circumference as a measure for
indicating need for weight management. British Medical Journal, 1995,
311:158-161.
14. Han TS et al. Waist circumference relates to intra-abdominal fat mass better
than waist:hip ratio in women. Proceedings of the Nutrition Society, 1995,
54:152A.
15. Pouliot MC et al. Waist circumference and abdominal sagittal diameter: best
simple anthropometric indexes of abdominal visceral adipose tissue
accumulation and related cardiovascular risk in men and women. American
Journal of Cardiology, 1994, 73:460-468.
16. Ross R et al. Quantification of adipose tissue by MRI: relationship with
anthropometric variables. Journal of Applied Physiology, 1992, 72:787-795.
17. Lean MEJ, Han TS, Deurenberg P. Predicting body composition by
densitometry from simple anthropometric measurements. American Journal
of Clinical Nutrition, 1996, 63:4-14.
18. Han TS et al. Waist circumference reduction and cardiovascular benefits
during weight loss in women. International Journal of Obesity and Related
Metabolic Disorders, 1997, 21: 127-134.
19. Bjorntorp P. Etiology of the metabolic syndrome. In: Bray GA, Bouchard C,
James WPT, eds. Handbook of obesity. New York, Marcel Dekker,
1998:573-600.
20. Dowling HJ, Pi-Sunyer FX. Race-dependent health risks of upper body
obesity. Diabetes, 1993, 42:537-543.
21. McKeigue PM. Metabolic consequences of obesity and body fat pattern:
lessons from migrant studies. In: Chadwick DJ, Cardew GC, eds. The
origins and consequences of obesity. Chichester, Wiley, 1996:54-67 (Ciba
Foundation Symposium 201 ).
22. Larsson Bet al. Is abdominal body fat distribution a major explanation for
the sex difference in the incidence of myocardial infarction? The study of
men born in 1913 and the study of women, Gbteborg, Sweden. American
Journal of Epidemiology, 1992, 135:266-273.
23. Han TS et al. Waist circumference action levels in the identification of
cardiovascular risk factors: prevalence study in a random sample. British
Medical Journal, 1995, 311:1401-1405.
24. Warden CH. Group report: How can we best apply the tools of genetics to
study body weight regulation? In: Bouchard C, Bray GA, eds. Regulation of
body weight: biological and behavioural mechanisms. Chichester, Wiley,
1996:285-305.
25. Measuring change in nutritional status. Geneva, World Health Organization,
1983.
14
15
3.
3.1
Introduction
Evidence is now emerging to suggest that the prevalence of overweight and obesity is increasing worldwide at an alarming rate. Both
developed and developing countries are affected. Moreover, as the
problem appears to be increasing rapidly in children as well as in
adults, the true health consequences may only become fully apparent
in the future.
The value of estimating the prevalence of, and secular trends in,
overweight and obesity cannot be overemphasized. Knowledge of the
level and changing distribution of overweight and obesity can be used
to:
-
A note of caution
Figure 3.1
BMI distribution: age-standardized proportions of selected categories in MONICA
populations, age group 35-64 years (men)
Country
Districtrrown
BMI
25-29.9
:0:30
Malta
France
USSR
Czechoslovakia
Germany, Fed. Rep.
Belgium
Switzerland
Hungary
Finland
German Dem. Rep.
Germany, Fed. Rep.
Finland
German Dem. Rep.
Italy
Yugoslavia
Finland
German Dem. Rep.
Poland
Italy
Canada
German Dem. Rep.
Hungary
Germany, Fed. Rep.
Germany, Fed. Rep.
USSR
Australia
France
Belgium
German Dem. Rep.
Poland
USSR
USSR
USSR
Switzerland
Sweden
Italy
Northern Ireland
Scotland
Belgium
Denmark
Iceland
USA
Spain
France
Australia
New Zealand
Sweden
China
of
of
of
of
< 25
Malta
Bas-Rhin
Kaunas
Czechoslovakia
Augsburg: rural
Charleroi
Ticino
Pecs
Turku/Loimaa
Rest of GDR-Monica
Augsburg: urban
Kuopio Province
Halle County
Area Latina
No vi-Sad
North Karelia
Kottbus County
Warsaw
Friuli
Halifax County
Kari-Marx-Stadt County
Budapest
Bremen
Rhein-Neckar Region
Novosibirsk: control
Newcastle
Lille
Luxembourg Province
Berlin-Lichtenberg
Tarnobrzeg Voivodship
Novosibirsk: intervention
Moscow: control
Moscow: intervention
Vaud/Fribourg
Northern Sweden
Area Brianza
Belfast
Glasgow
Ghent
Glostrup
Iceland
Stanford
Catalonia
Haute-Garonne
Perth
Auckland
Gothenburg
Beijing
20
40
60
80
100
Note 1. The proportions of men classified as obese, overweight and normal weight in 48
populations (mainly European) taking part in the WHO MONICA study are shown.
Although these populations are not necessarily representative of the countries in which
they are located, they can be compared because the data were collected in the same
time period, are age-standardized, and are based on heights and weights measured in
accordance with identical protocols. The WHO MONICA study has generated one of the
most comprehensive data sets on the prevalence of obesity worldwide. The data were
collected over the period 1983-1986 (3).
Note 2. Names of countries are those that were valid at the time of data collection.
18
Figure 3.2
BMI distribution: age-standardized proportions of selected categories in MONICA
populations, age group 35-64 years (women)
Country
District/Town
BMI
"30
USSR
USSR
USSR
Malta
USSR
USSR
Poland
Czechoslovakia
Italy
Yugoslavia
German Dem. Rep.
Belgium
Hungary
Poland
German Dem. Rep.
Spain
France
Finland
German Dem. Rep.
Germany, Fed. Rep.
Finland
German Dem. Rep.
Italy
Germany, Fed. Rep.
Hungary
France
Belgium
German Dem. Rep.
Finland
Canada
Scotland
Germany, Fed. Rep.
Italy
USA
Belgium
Switzerland
Australia
Northern Ireland
Sweden
Germany, Fed. Rep.
Switzerland
Iceland
France
Denmark
Australia
Sweden
New Zealand
China
of
of
of
of
< 25
25-29.9
Kaunas
Novosibirsk: intervention
Novosibirsk: control
Malta
Mo~cow: intervention
Moscow: control
Tarnobrzeg Voivodship
Czechoslovakia
Area Latina
Novi-Sad
Rest of GDR-Monica
Charleroi
Pecs
Warsaw
Halle County
Cataloia
Bas-Rhin
North Karelia
Kottbus County
Augsburg: rural
Kuopio province
Kari-Marx-Stadt County
Friuli
Bremen
Budapest
Lille
Luxembourg Province
Berlin-Lichtenberg
Turku/Loimaa
Halifax County
Glasgow
Augsburg: urban
Area Brianza
Stanford
Ghent
Ticino
Newcastle
Belfast
Northern Sweden
Rhein-Neckar Region
Vaud/Fribourg
Iceland
Haute-Garonne
Glostrup
Perth
Gothenburg
Auckland
Beijing
20
40
60
80
100
Note 1. The proportions of women classified as obese, overweight and normal weight in 48
populations (mainly European) taking part in the WHO MONICA study are shown.
Although these populations are not necessarily representative of the countries in which
they are located, they can be compared because the data were collected in the same
time period, are age-standardized, and are based on heights and weights measured in
accordance with identical protocols. The WHO MONICA study has generated one of the
most comprehensive data sets on the prevalence of obesity worldwide. The data were
collected over the period 1983-1986 (3).
Note 2. Names of countries are those that were valid at the time of data collection.
19
compared because the data were collected in the same time period,
are age-standardized, and are based on weights and heights measured
in accordance with identical protocols. The data presented were collected in the first round between 1983 and 1986, and more recent data
have been published since the time of the WHO Consultation. 1 The
majority of the data are for European populations.
Figs 3.1 and 3.2 show the BMI distributions in 48 MONICA populations for men and women, respectively (3). Although this report
focuses on data relating to obesity, i.e. BMI ~30, it is important to
note that a BMI between 25 and 29.9 is responsible for the major
part of the impact of overweight on certain obesity comorbidities;
it has been estimated, for example, that about 64% of male and 77%
of female cases of NIDDM would theoretically be prevented if no
one had a BMI ~25. These figures may be compared with those for a
BMI cut -off point of less than 30, namely 44% and 33%, respectively
(4, 5).
Figs 3.1 and 3.2 show that, in all but one male population, and in the
majority of female populations, between 50% and 75% of adults aged
35-64 years were either overweight or obese during the period 19831986. In a few populations, this figure was over 75%. Thus, between
1983 and 1986, the majority of adults in these populations were at
increased risk of illness due to overweight or obesity. Based on the
evidence that the prevalence of obesity is increasing worldwide, the
situation is now likely to be even worse.
3.4
African Region
Many countries in the African Region have necessarily focused principally on undernutrition and food security. As a result, trends in
obesity have been documented in only a few African countries or
populations. However, one recent study in Mauritius has shown the
same trend as that seen in the other five WHO regions- a dramatic
increase in obesity prevalence over a five-year period in both men and
women aged 25-74 years. The proportion of obese men increased
from 3.4% in 1987 to 5.3% in 1992, while the proportion of obese
women increased from 10.4% to 15.2% in the same period. This
increase was seen in all age groups and ethnic groups (6, 7). Although
1
20
Table 3.1
Obesity prevalence (BMI 2': 30) in some African countries and populations
Country or population
Ghana
Mali
Mauritius
Rodrigues (creoles)
South Africa, Cape
Peninsula (blacks)
United Republic of
Tanzania
Year
Age
(years)
Prevalence of obesity(%)
Reference
Women
Men
0.9
0.8
8
8
7
1987-1988
1991
1992
1992
1990
20+
20+
25-74
25-69
15-64
5
10
8
15
31
44
10
1986-1989
35-64
0.6
3.6
11
Secular trend data are available for Brazil, Canada and the USA, and
are summarized in Table 3.2. These data indicate that obesity rates for
both men and women are increasing not only in developed countries,
but also in developing countries and in countries such as Brazil going
through rapid socioeconomic transition.
21
Table 3.2
Trends in obesity (BMI
Country
Brazil
Canada
United States
of America
::e:
Year
1975
1989
1978
1981
1988
1986-1990
1960-1962
1971-1974
1976-1980
1988-1994
Age
(years)
25-64
25-64
20-70
20-70
20-70
18-74
20-74
20-74
20-74
20-74
Prevalence of obesity(%)
Men
Women
3.1
5.9
6.8
8.5
9.0
15.0
8.2
13.3
9.6
9.3
9.2
15.0
15.1
16.1
16.5
24.9
10.4
11.8
12.3
19.9
Reference
15
15
16
17
18
19
14
14
14
14
The most recent data for the prevalence of obesity in the USA are
those from NHANES Ill (1988-1994). A recent reanalysis of the data
22
Table 3.3
Obesity prevalence (BMI
Country
Brazil
Canada
USA
Year
1989
1986-1990
1988-1994
Prevalence of obesity(%)
Men
6
15.0
19.9
Reference
Women
13
15.0
24.9
15
19
14
Good-quality, nationally representative, secular trend data for countries in the South-East Asia Region were unavailable. However, data
from two studies conducted by the same research centre in Thailand
do suggest that diet-related chronic diseases, including obesity, are
increasing in affluent urban populations. The first study was conducted in 1985 among 35-54-year-old Thai officials; it was found that
2.2% of the 2703 men, and 3.0% of the 792 women, had a BMI 230
(21). The second study in 1991 was smaller (66 men and 453 women),
and had a broader age range (19-61 years), but also assessed nutritional factors in affluent urban Thais. Results of this study showed
that 3.0% of men and 3.8% of women had a BMI 230. Prevalence
23
figures for BMI 25-29.9 were considerably higher (15.2% in men and
23.2% in women) (22).
3.6.2 Current prevalence of obesity
Only limited obesity prevalence data are available for countries in the
Region. Various studies on nutritional status have been carried out,
particularly in India, but these have generally been on undernutrition
and on selected population groups and have not used the WHO
classification of obesity. As many countries in south-east Asia are
currently going through the so-called "nutrition transition"/ there is a
special need to collect good-quality, nationally representative obesity
prevalence data. The nutrition transition is associated with a change
in the structure of the diet, reduced physical activity and rapid
increases in the prevalence of obesity (23).
3.7
European Region
24
The rapid transition, or shift, from the problem of dietary deficit (or undernutrition) to one
of dietary excess (or overnutrition and/or unbalanced nutrition).
Updated material has been published since the Consultation: Tunstaii-Pedoe H et al.
Contribution of trends in survival and coronary-event rates to changes in coronary heart
disease mortality: 10-year results from 37 WHO MONICA project populations. Lancet,
1999, 3531547-1557.
Table 3.4
Trends in obesity (BMI ;::: 30) in selected European countries
Country
England
Finland
Former German
Democratic
Republic
Netherlands
Sweden
Year
1980
1986-1987
1991
1994
1995
1978-1979
1985-1987
1991-1993
1985
1989
1992
1987
1988
1989
1990
1991
1992
1993
1994
1995
1980-1981
1988-1989
Age
(years)
16-64
20-75
25-65
2Q-29
16-84
Men
Women
6.0
7
12.7
13.2
15.0
10
12
14
13.7
13.4
20.5
8.0
12
15.0
16.0
16.5
10
10
11
22.2
20.6
26.8
6.0
6.3
6.2
7.4
7.5
7.5
7.1
8.8
8.4
4.9
5.3
8.5
7.6
7.4
9.0
8.8
9.3
9.1
9.4
8.3
8.7"
9.1 8
Reference
26
27
24
28
L. Heinman,
personal
communication,
1996
29
30
Good-quality, nationally representative, secular trend data for countries in the Eastern Mediterranean Region are not available.
25
Table 3.5
Obesity prevalence (BMI
Country
Former
Czechoslovakia
England
Finland
Former Federal
Republic of
Germany
Former German
Democratic
Republic
Netherlands
Year
Age
(years)
Prevalence of obesity(%)
Men
Reference
Women
1988
20-65
16
20
1995
1991-1993
1990
16-64
20-75
25-69
15
14
17
16.5
11
19
1992
25-69
21
27
1995
20-59
V. Hainer,
personal
communication,
1997; 31
24
28
32
L. Heinman,
personal
communication,
1996
29
Table 3.6
Obesity prevalence (BMI :2: 30) in selected Eastern Mediterranean countries
Country
Bahrain:
Urban
Rural
Cyprus
Iran, Islamic
Republic of
(south)
Kuwait
Saudi Arabia:
Total
Urban
Rural
United Arab
Emirates
Year
1991-1992
Age
(years)
Prevalence of obesity(%)
Men
Women
9.5
6.5
19
2.5
30.3
11.2
24
7.7
32
41
16
18
12
16
24
28
18
38
35
20-65
1989-1990
1993-1994
35-64
20-74
1994
1990-1993
18+
15+
1992
17+
Reference
13
36
37
33
34
men were obese (34). In Bahrain, obesity was more common in urban
than in rural areas, especially in women (35).
Finally, a recent study in the south of the Islamic Republic of Iran
revealed that obesity is prevalent in the adult population, and is more
frequent among women than men (36).
3.9
Table 3.7
Trends in obesity (BMI ;::: 30) in selected Western Pacific countries
Country
BMI
cut-off
Australia
27
China
30
26.4
Japan
30
Samoa:
Urban
Rural
30
30
Year
Age
(years)
1980
1983
1989
1989
1991
1989
1991
25-64
1976
1982
1987
1993
1976
1982
1987
1993
1978
1991
1978
1991
20+
Prevalence of obesity(%)
Men
Women
9.3
9.1
11.5
8.0
10.5
13 2
4.3
4.3
0.89
0.86
20--45
20-45
2.9
0.29
0.36
20+
25-69
25-69
7.1
8.4
10.3
11.8
0.7
0.9
1.3
1.8
38.8
58.4
17.7
41.5
12.3
12.3
12.6
130
2.8
2.6
2.8
2.6
59.1
76.8
37.0
59.2
Reference
38
39
C. Chunm1ng,
personal
communication
S. lnoue,
personal
communication
S. lnoue,
personal
communication
40
40
Data for 1989 and 1991 from the China Health and Nutrition Survey
(CHNS) show an increase in the proportion of adult men, but not
women, who are severely overweight (BMI ~ 27) and obese (BMI ~
30) (39). This longitudinal survey, which is now under way, is considered to be representative of all provinces in China. As the plan is for
surveys to be conducted every two years, the CHNS should prove a
valuable source of data for documenting the secular trends in obesity
in a country in economic transition. Data from the 1993 survey have
been published since the time of the WHO Consultation. 1
Secular trends have also been observed in Samoa, where there has
been a marked increase in the prevalence of obesity between 1978
28
Wang Y, Popkin B, Zhai F. The nutritional status and dietary pattern of Chinese
adolescents, 1991 and 1993. European Journal of Clinical Nutrition, 1998, 52(12):908916.
Guo X et al. Food price policy can favorably alter macronl!trient intake in China. Journal
of Nutrition, 1999, 129:994-1001.
and 1991, especially among men living in rural areas. Obesity is not
new to Pacific populations and has long been regarded as attractive
and a symbol of high social status and prosperity (40). However, there
is evidence that these traditional notions are being replaced by an
image of small body size (41).
3.9.2 Current prevalence of obesity
Table 3.8 shows the most recent estimates of obesity rates in a number
of countries in the Western Pacific. The prevalence of obesity in the
general population of both Australia and New Zealand appears to be
in the range 10-15%. Studies of Aborigines living in different regions
of Australia are not consistent with this finding; depending on the
degree of "westernization" of Aboriginal communities, they have
either a much higher or a substantially lower prevalence of obesity
than the general Australian population (42).
Interim data from the Japanese National Nutrition Survey show that
the prevalence of obesity in Japan is around 2% in males and 3%
in females. When a BMI cut-off point of 26.4 is used (2120% of
standard body weight (SBW)), the figures are around 12% and 13%,
respectively. Various studies have also been conducted on specific
population groups and centres within Japan (S. Inoue, personal
communication).
The current prevalence of obesity in China is probably best documented by the 1992 third Nationwide Nutritional Survey (NNS Ill).
This survey was conducted throughout both urban and rural provinces, and data were collected from a larger representative sample of
men (n = 14964) and women (n = 14590) aged 20-45 years than the
CHNS cohort (n = 5000 approximately). Data from NNS Ill show that
obesity does exist in China, albeit at a low prevalence, is more common in women than in men (Table 3.8), and is more prevalent in
urban than in rural areas. These findings are supported by a study in
11478 randomly selected Chinese adults aged 40 years and older,
although slightly higher rates were reported than in the younger age
group studied in NNS Ill (C. Chunming, personal communication). A
number of other data sets are available but the WHO classification of
obesity is rarely used in them, they are not age-standardized and tend
not to be nationally representative.
The most striking feature of Table 3.8 is the extremely high agestandardized prevalence of obesity observed in the Pacific island
populations of Melanesia, Micronesia and Polynesia. In urban Samoa,
for example, the prevalence of obesity has been estimated to be
over 75% in adult women and almost 60% in adult men. However,
29
Table 3.8
Obesity prevalence (BMI
Country
Year
Prevalence of obesity(%)
Men
Women
Australia
China
1989
1992
25-64
20-45
11.5
1.20
13.2
1.64
Japan
1993
20+
1.7
2.7
Nauru (Micronesia)
New Zealand
Papua New Guinea
(Melanesia):
Coastal urban
Coastal rural
Highlands
Samoa (Polynesia):
Urban
Rural
1987
1989
25-69
18-64
64.8
10
70.3
13
1991
25-69
36.3
23.9
4.7
54.3
18.6
5.3
584
41.5
76.8
59.2
1991
Reference
38
C. Chunming,
personal
communication
S. lnoue,
personal
communication
40
43
40
25-69
40
BMI distribution varies significantly according to the stage of development reached in a transitional society. As the proportion of the
30
Figure 3.3
BMI distribution of various adult populations worldwide (both sexes)
Overweight
Thinness
Peru
Tunisia
Colombia
Brazil
Costa Rica
Cuba
Morocco
Chile
Mexico
Togo
Zimbabwe
China
Mali
Ghana
Haiti
Senegal
Ethiopia
India
BMI Classes
D< 16 016-16.9
D 11-18.4 1111 >25
L_~~~~~======~~--~--~~--~~
60
50
40
30
20
10
10
% Population
20
30
40
50
60
WH098275
There is a tendency for an almost symmetrical increase in the proportion of a population with
high BMI as the proportion of the population with low BMI decreases.
a
32
The Z-score is the deviation of an individual's value from the median value of a
reference population divided by the standard deviation of the reference population.
Figure 3.4
Prevalence of obese preschool children (0-59 months) in selected countries and
territories
Papua New Guinea
Bangladesh
Philippines
Burkina Faso
Singapore
Togo
Tunisia
Rwanda
India
Indonesia
Belize
Jordan
Tahiti
Nicaragua
Brazil
Saint Lucia
United Kingdom
Yugoslavia
Antigua
Zambia
Venezuela
Italy
Panama
Peru
Barbados
Honduras
Lesotho
Bolivia
Trinidad & Tobago
Iran (Islamic Republic of)
Mauritius
Canada
Jamaica
Chile
0
10
References
1. World health statistics annual 1995. Geneva, World Health Organization,
1996.
17. Canadian standardized test of fitness: operations manual, 3rd ed. Ottawa,
Fitness Canada, 1986.
18. Stephens T, Craig CL. The well-being of Canadians: highlights of the 1988
Campbe/l's Survey, Ottawa, Canadian Fitness and Lifestyle Research
Institute, 1990.
19. Reeder BA et al. Obesity and its relation to cardiovascular disease risk
factors in Canadian adults. Canadian Medical Association Journal, 1992,
146:2009-2019.
20. Forrester T et al. Obesity in the Caribbean. In: Chadwick DJ, Cardeau G,
eds. The origins and consequences of obesity. Chichester, Wiley, 1996:1731.
21. Tanphaichitr V et al. Prevalence of obesity and its associated risks in urban
Thais. In: Oomura Yet al., eds. Progress in obesity research, London, John
Libbey, 1990:649-653.
22. Leelahagul P, Tanphaichitr V. Current status on diet-related chronic
diseases in Thailand. Internal Medicine, 1995, 11:28-33.
23. Popkin BM. The nutrition transition in low-income countries: an emerging
crisis. Nutrition Reviews, 1994, 52:285-298.
24. Prescott-Ciarke P, Primatesta P. Health survey for England 1995. London,
Her Majesty's Stationery Office, 1997.
25. Pietinen P, Vartiainen E, Mannisto S. Trends in body mass index and
obesity among adults in Finland from 1972 to 1992. International Journal of
Obesity and Related Metabolic Disorders, 1996, 20:114-120.
26. Obesity: reversing the increasing problem of obesity in England. A report
from the Nutrition and Physical Activity Task Forces. London, Department of
Health, 1995.
27. Colhoun H, Prescott-Ciarke P. Health survey for England 1994. London, Her
Majesty's Stationery Office, 1996.
28. Seidell JC, Rissanen AM. Time trends in the worldwide prevalence of
obesity. In: Bray GA, Bouchard C, James WPT, eds. Handbook of obesity.
New York, Marcel Dekker, 1998:79-91.
29. Seidell JC. Time trends in obesity: an epidemiological perspective.
Hormone and Metabolic Research, 1997, 29:155-158.
30. Kuskowska-Wolk A, Bergstrom R. Trends in body mass index and
prevalence of obesity in Swedish women 1980-89. Journal of Epidemiology
and Community Health, 1993, 47:195-199.
31. Hainis K, Petrasek R. Body height, weight and BMI for the Czech and
Slovak populations. Homo, 1999, 52:163-182.
32. Hoffmeister H, Mensink GBM, Stolzenberg H. National trends in risk factors
for cardiovascular diseases in Germany. Preventive Medicine, 1994,
23:197-205.
33. AI-Nuaim A et al. Prevalence of diabetes mellitus, obesity and
hypercholesterolemia in Saudi Arabia. In: Musaiger AO, Miladi SS, eds.
Diet-related non-communicable diseases in the Arab countries of the Gulf.
Cairo, Food and Agriculture Organization of the United Nations, 1996:73-81.
35
49. ai-Nuaim AR, Bamgboye EA, ai-Herbish A. The pattern of growth and
obesity in Saudi Arabian male school children. International Journal of
Obesity and Related Metabolic Disorders, 1996, 20:1000-1005.
50. Diet, nutrition and the prevention of chronic diseases. Report of a WHO
Study Group. Geneva, World Health Organization, 1990 (WHO Technical
Report Series, No. 797).
51. WHO Global Database on Child Growth and Malnutrition. Geneva, World
Health Organization, 1997 (unpublished document WHO/NUT/97.4, available
on request from Department of Nutrition for Health and Development, World
Health Organization, 1211 Geneva 27, Switzerland).
52. Gurney M, Gorstein J. The global prevalence of obesity- an initial
overview of available data. World Health Statistics Quarterly, 1988, 41:251254.
53. Popkin BM, Richards MK, Monteiro CA. Stunting is associated with
overweight in children of four nations that are undergoing the nutrition
transition. Journal of Nutrition, 1996, 126:3009-3016.
37
PART 11
38
4.
4.1
Introduction
overweight patients and are often the primary reason for contact
with the health care system. Most of these conditions can be improved with modest weight loss.
The psychosocial consequences of obesity. These have important
implications for disease management, and are compounded by the
fact that health professionals often view obese individuals as weakwilled and unlikely to benefit from counselling.
The association between obesity and certain psychosocial consequences m adolescence, and the persistence of obesity into
adulthood.
4.2
Figure 4.1
Relationship between (a) BMI, (b) cholesterol and (c) diastolic blood pressure
and relative risk of mortality
Moderate risk
Low risk
High risk
(a) 2.5
2.0
~
VI
.:::
~
1.5
'+='
Ill
Qj
0:::
1.0
0.5
20
25
35
30
BMI
(b)
VI
.:::
~
-.::;
Ill
Qj
0:::
3.8
5.2
7.5
6.1
Cholesterol (mmoUI)
(c)
5
4
~
VI
.:::
~
'+J
Ill
Qj
0:::
75
80
85
90
95
100
105
110
115
120
Adapted from reference 2 with the permission of the publisher. Copyright John Wiley & Sons
Ltd. Based on data from Stamler et al. (3, 4) for the construction of the blood pressure and
cholesterol plots, and from the Nurses' Health Study (5) for the BMI plot. There are similar
continuous graded increases in the RR of mortality as BMI, blood pressure and cholesterol
increase. However, the RR rises more rapidly for cholesterol and blood pressure than it does
for BM I. The rise in the RR of mortality is notably steeper from BMI >30, cholesterol >6 mmol/
litre, and diastolic blood pressure> 100 mmHg (13.3 kPa).
41
Table 4.1
Relative risk of health problems associated with obesity"
Greatly increased
(relative risk much
greater than 3)
Moderately increased
(relative risk 2-3)
Slightly increased
(relative risk 1-2)
NIDDM
CHD
Gallbladder disease
Hypertension
Dyslipidaemia
Insulin resistance
Breathlessness
Sleep apnoea
Osteoarthritis (knees)
Hyperuricaemia and gout
These differences make intra-abdominal adipose tissue more susceptible to both hormonal stimulation and changes in lipid accumulation
and metabolism. Furthermore, intra-abdominal adipocytes are
located upstream from the liver in the portal circulation. This means
that there is a marked increase in the flux of nonesterified fatty acid
(NEFA) to the liver via the portal blood in patients with abdominal
obesity.
There is good evidence that abdominal obesity is important in the
development of insulin resistance (see section 4.8.1), and in the metabolic syndrome (hyperinsulinaemia, dyslipidaemia, glucose intolerance, hypertension) that links obesity with CHD (see section 4.8.2).
Some non-Caucasian populations appear to be especially susceptible
to this type of syndrome, in which lifestyle changes may play a particularly important etiological role (7).
Premenopausal women have quantitatively more lipoprotein lipase
(LPL) and higher LPL activity in the gluteal and femoral subcutaneous regions, which contain fat cells larger than those in men, but
these differences disappear after the menopause (8). In contrast,
men show minimal regional variations in LPL activity or fat cell size.
These differences may explain the tendency for premenopausal
women to deposit fat preferentially in lower body fat depots. The
higher level of intra-abdominal adipose tissue found in men compared with premenopausal women seems to explain, in part, the
greater prevalence of dyslipidaemia and CHD in men than in premenopausal women.
4.6
Obesity-related mortality
Figure 4.2
Relationship between BMI and relative risk of premature mortality
2.5
-~
lii
All women
Women who never smoked
2.0
Women who never smoked
and recently had stable weight
~
Q)
e;
0
~
;::
"'
1.5
~
.p
CO
&
1.0
The relationship between BMI and all-cause mortality was examined using data from the
Nurses' Health Study, which involved 115195 middle-aged women. A total of 4726 deaths
occurred during the 16-year follow-up. The apparent excess relative risks of mortality associated with leanness, suggested when the analysis included all women, were found to be
artefacts as they were eliminated by accounting for smoking (leaving 1499 deaths) and
subclinical disease (leaving 531 deaths). By excluding former and current smokers, women
with BMI < 22 were found to have the lowest mortality among the remaining women. When
disease-related health loss was also accounted for, the leanest women (BM I < 19) had the
lowest mortality. This analysis is based on professional middle-aged women and so may not
be representative of all population groups.
a
Based on data from Manson et al. (5), with permission, and reproduced from Gill PG, Key
issues in the prevention of obesity, British Medical Bulletin, 1997, 53:359-388, with the
permission of the publisher, Churchill Livingstone.
factors but are to a large degree the effects of obesity (hence some
factorial analyses distort the true association between obesity and
mortality), failure to control for weight loss associated with illness
(leading to an underestimate of the impact of obesity on mortality),
and failure to standardize for age (9, 10).
The Nurses' Health Study (5) in the USA found that, when biases are
removed from the analysis, an almost linear, continuous relationship
between BMI and mortality is found, with no specific lower threshold
(see Fig. 4.2). This is not surprising, given the largely linear relationship between body weight and conditions such as CHD, hypertension
and NIDDM when BMI increases from 20 to 30 (11-13). Similar
results and conclusions have been reached by others (10, 14) but a
45
Cardiovascular disease
that obesity is also important as an independent risk factor for CHDrelated morbidity and mortality (18). The Framingham Heart Study
ranked body weight as the third most important predictor of CHD
among males, after age and dyslipidaemia (19). Similarly, in women,
a large-scale prospective study in the USA found a positive correlation between BMI and the risk of developing CHD. Weight gain
substantially increased this risk (20). These findings are consistent
with data from other countries. A 15-year follow-up study of 16000
men and women in eastern Finland concluded that obesity is an
independent risk factor for CHD mortality in men and contributes to
the risk of CHD in women (21).
On the basis of the Framingham Heart Study and other studies, it can
be concluded that the degree of overweight is related to the rate of
development of CVD (22). The CHD risk associated with obesity is
higher in younger age groups and also in people with abdominal
obesity than in those with excess fat around the hips and thighs (23)
(see section 4.5). In addition, mortality from CHD has been shown to
be increased in overweight individuals, even at body weights only
10% above the average (24).
Interestingly, Asian Indians have the highest rates of CHD of any
ethnic group studied, despite the fact that nearly half this group are
lifelong vegetarians. CHD occurs at an early age and generally follows a severe and progressive course. Although the prevalence of
classic risk factors is relatively low, there is a substantial prevalence in
this population of high triglyceride and low high-density lipoprotein
(HDL) cholesterol levels, high lipoprotein (a) levels, hyperinsulinaemia and abdominal obesity (25). These appear to constitute weightrelated risk factors in this population that may, in particular, reflect
the central distribution of body fat.
Hypertension and stroke
The association between hypertension and obesity is well documented. Both systolic and diastolic blood pressure increase with BMI,
and the obese are at higher risk of developing hypertension than lean
individuals (4, 26). Community-wide surveys in the USA (NHANES
11) show that the prevalence of hypertension in overweight adults is
2.9-fold higher than that for non-overweight adults (27). The risk in
those aged 20-44 years is 5.6 times greater than that in those aged 4574 years (28), which in turn is twice as high as that for non-overweight
adults (29). The risk of developing hypertension increases with the
duration of obesity, especially in women, and weight reduction leads
to a fall in blood pressure (see section 5.3.1).
47
Table 4.2
Cancers with a higher reported incidence in obese persons
Hormone-dependent
Gastrointestinal/hepatic/renal
Endometrial
Ovarian
Breast
Cervical
Prostate
Colorectal
Gallbladder
Pancreatic
Hepatic
Renal
increased risk of breast cancer. For example, it has been reported that
an increase in intra-abdominal fat accumulation increases the risk of
postmenopausal breast cancer, independently of relative weight and
particularly when there is a family history of the disease. Furthermore, weight gain during adulthood has consistently been associated
with increased risk of breast cancer, even in cohort studies that
showed no association between baseline relative weight and subsequent risk of breast cancer (40, 41).
In one major prospective study, in which 750000 men and women
were followed for 12 years, it was found that the mortality ratios 1 for
any cancer were 1.33 and 1.55 for obese men and women, respectively
( 42). It should be noted, however, that in some studies of gastrointestinal and breast cancer, it has been difficult to determine whether it is
the effect of dietary components that promote weight gain, such as a
high fat content, or the effect of obesity per se that is important.
Further research in this area is necessary.
High levels of physical activity have been shown to decrease the risk
of colon cancer in men in the majority of studies, and in women in half
the studies. However, the effect of physical activity on rectal cancer
was not significant in most cases. Breast cancer and cancers of the
reproductive system were less prevalent in women who had been
athletes at college (43) compared with less active women. NHANES
I data indicate that a high level of non-recreational activity is important in reducing the risk of cancer, but that there is only a
weak relationship between recreational exercise and cancer, with the
exception of prostate cancer (44).
4. 7.3 Diabetes mellitus
Ratio of premature deaths (<65 years) in a population with BMI ?30 to premature deaths
in a population with BMI <25.
49
the Nurses' Health Study suggest that even moderate overweight may
increase the risk (70).
Supersaturation of the bile with cholesterol and reduced motility of
the gallbladder, both of which are present in the obese, are thought to
be factors underlying gallstone formation. Furthermore, since gallstones enhance the propensity to gallbladder inflammation, acute and
chronic cholecystitis is also more common in the obese. Biliary colic
and acute pancreatitis are other potential complications of gallstones.
Paradoxically, gallstones are also a common clinical problem in those
losing weight (see section 5).
4.8
Recent research has shown that adipocytes (fat cells) are more than
just fat depots. They also function as endocrine cells, producing many
locally and distantly acting hormones, and as target cells for a great
many hormones. Altered hormonal patterns have been observed in
obese patients, especially in those with intra-abdominal fat accumulation (71, 72). Common hormonal abnormalities associated with intraabdominal fat accumulation are listed in Table 4.3.
Insulin resistance
51
who is gaining weight continues to eat the same amount, there will
come a time at which net fat oxidation will, through insulin resistance,
equal dietary fat intake and the individual will be in fat balance. A
corollary, suggested by data from prospective studies (74), is that the
more insulin resistant among a group of individuals of normal body
weight will be protected from future weight gain. However, this is
only a theory and is by no means universally accepted (75). In addition, insulin resistance is clearly maladaptive in terms of risk of CVD
and other chronic diseases.
Insv Ii:J norm:::.Uy inhibits fat mobilization from adipose tissue and
activates LPL. These are both metabolic processes that become insulin resistant in obesity. However, in contrast to the direct regulation of
insulin secretion by plasma glucose concentration, the regulation of
insulin secretion by fat metabolites is relatively weak. This means that
oversecretion of insulin (due to insulin resistance) compensates for
defects in glucose metabolism to a much greater degree than for
defects in lipid metabolism. Disruption of the postprandial response
by insulin leads to the dyslipidaemic state (section 4.8.2). Differential
insulin resistance of specific organs or tissues may account for
regional fat accumulation. For instance, the relative insulin sensitivity
of intra-abdominal fat is thought to be required for central fat accumulation.
Physical activity improves insulin sensitivity through weight reduction
and increased cardiorespiratory fitness. However, it also improves
insulin sensitivity independently of these factors (76).
Hormones affecting reproductive function
Significant associations are seen in reproductive endocrinology between excess body fat, particularly abdominal obesity, and ovulatory
dysfunction, hyperandrogenism and hormone-sensitive carcinomas
(77). Changes in circulating sex hormones appear to underlie these
abnormalities. Androstenedione and testosterone concentrations are
commonly elevated whereas that of sex hormone binding globulin
(SHBG) is reduced, while the plasma ratio of estrone to estradiol is
also increased in obesity. A decrease in SHBG is associated with an
increased clearance of free testosterone and estradiol, resulting in a
disturbed sex hormone equilibrium.
Moderate obesity is frequently associated with polycystic ovary syndrome, which is the most common endocrine disorder of reproduction
(78). Obesity contributes to or worsens, and weight loss generally
improves, the associated hormonal abnormalities and menstrual function of obese women with polycystic ovary syndrome (79).
52
Adrenocortical function
Obese subjects have a normal circulating plasma cortisol concentration with a normal circadian rhythm, and normal urinary free cortisol.
However, the cortisol production rate is increased in obesity to compensate for an accelerated rate of cortisol breakdown (80, 81). Cortisol inhibits the antilipolytic effect of insulin in human adipocytes, an
effect that may normally be particularly pronounced in abdominal fat
because it contains a high density of glucocorticoid receptors. This
mechanism may contribute to the manifestations of insulin resistance
(82).
Studies have shown that patients with intra-abdominal fat accumulation have increased cortisol secretion, probably because they have
increased activity of the hypothalamic-pituitary axis (HPA). Stress,
alcohol and smoking have all been shown to stimulate the activity of
the HPA (83).
4.8.2 Metabolic disturbances
Dyslipidaemia
Obesity impairs respiratory function and structure, leading to physiological and pathophysiological impairments. The work of breathing
is increased in obesity, mainly as a result of the extreme stiffness of
the thoracic cage consequent on the accumulation of adipose tissue in
and around the ribs, abdomen and diaphragm (92). Hypoxaemia is
common, partly because the low relaxation volume causes ventilation
to occur at volumes below the closing volume (93, 94), and is exacerbated when lying down because of the reduced functional residual
capacity (95).
Sleep apnoea occurs in more than 10% of men and women with a
BMI of 30 or above, and 65-75% of individuals with obstructive sleep
apnoea are obese. In one study, sleep apnoea occurred in 77% of
those with a BMI above 40. In addition to BMI, however, obstructive
sleep apnoea is related to central obesity and to neck size, probably as
a result of the narrowing of the upper airway when lying down. The
nocturnal disruption of sleep is associated with daytime somnolence,
hypercapnia, morning headaches, pulmonary hypertension and, eventually, right ventricular failure (96, 97).
4.10 Psychological problems associated with obesity
Many obese people have an altered body image, i.e. they see their
bodies as ugly and believe that others wish to exclude them from
social interaction. This occurs most often in young women of middle
and upper socioeconomic status, among whom obesity is less prevalent, and in those who have been obese since childhood.
4.1 0.4 Eating disorders
disturbances such as sleep apnoea. It is thought to be due to alterations in the circadian rhythm, affecting both food intake and mood.
Nocturnal sleep-related disorder is a newly delineated night-eating
pattern characterized by eating on arousal from sleep. It may be a
variant of binge-eating disorder but its relationship with night-eating
syndrome is unclear.
There is no clear evidence that these eating disorders are the primary
cause of weight gain. It has been suggested that the increasing incidence of eating disorders is associated with the psychological pressure
to slim (110, 111). The fact that these disorders do not exist in societies where obesity is accepted as normal strongly supports the view
that they have a cultural basis. Once established in patients, however,
they are serious medical conditions and are difficult to cure.
4.11 Health consequences of overweight and obesity in childhood
and adolescence
4.11.1 Prevalence
Obesity-related symptoms in children and adolescents include psychosocial problems, increased CVD risk factors, abnormal glucose
metabolism, hepatic-gastrointestinal disturbances, sleep apnoea and
orthopaedic complications (Table 4.4).
The most important long-term consequence of childhood obesity is its
persistence into adulthood, with all the associated health risks. Obesity is more likely to persist when its onset is in late childhood or
adolescence and when the obesity is severe (112, 113). Overweight in
adolescence has also been shown to be significantly associated with
long-term mortality and morbidity (114).
Table 4.4
Health consequences of childhood obesity
High prevalence
Intermediate prevalence
Low prevalence
Faster growth
Psychosocial problems
Persistence into
adulthood (for lateonset and severe
obesity)
Dyslipidaemia
Hepatic steatosis
Abnormal glucose metabolism
Persistence into adulthood
(depending on age of
onset and severity)
Orthopaedic complications
Sleep apnoea
Polycystic ovary syndrome
Pseudotumour cerebri
Cholelithiasis
Hypertension
58
The most common consequence of obesity in children in industrialized countries is poor psychosocial functioning. Preadolescent children associate the shape (or silhouette) of an overweight body with
poor social functioning, impaired academic success and reduced fitness and health (115), as well as with character defects (see p. 56).
However, there is little evidence to suggest that self-esteem is significantly affected in obese young children (106, 116).
Among teenagers, however, cross-sectional studies consistently show
an inverse relationship between body weight and both overall selfesteem and body image (106). A marked self-awareness of body
shape and physical appearance develops during adolescence so that it
is perhaps not surprising that the pervasive, negative social messages
associated with obesity in many communities have a major impact at
this stage. Overweight in adolescence may also be associated with
later social and economic problems. A large prospective study conducted in the USA has shown that women who were overweight
during adolescence and young adulthood were more likely to have
lower family incomes, higher rates of poverty and lower rates of
marriage than women with various other forms of chronic physical
disability during adolescence (102).
4.11.3 Cardiovascular risk factors
Hepatic complications in obese children have been reported, particularly hepatic steatosis characterized by raised serum transaminase
levels (124). Abnormal liver enzymes may be associated with cholelithiasis, but this condition is rare in children and adolescents.
Gastro-oesophageal reflux and gastric emptying disturbances, which
affect a minority of obese children, may be a consequence of raised
intra-abdominal pressure due to increased abdominal fat.
59
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68
5.
5.1
Introduction
Data from a number of studies have shown that modest weight loss
(defined as a weight loss of up to 10%) improves glycaemic control,
and reduces both blood pressure and cholesterol levels (1). Modest
weight loss also improves lung function and breathlessness, reduces
the frequency of sleep apnoea, improves sleep quality, and reduces
daytime somnolence. However, the degree of improvement often
depends on the length of time that the condition has been present.
Modest weight loss will also alleviate osteoarthritis, depending on the
degree of structural damage, as well as back and joint pain.
5.3.2 Extensive weight loss
intentional weight loss was best seen in those of poorer health status
(4).
In a randomized controlled dietary intervention trial of post-infarct
patients in India, the effect of dietary intervention on cardiac mortality was greatest among patients who had also lost around 10% of their
body weight (5). Further longer-term, well controlled studies are thus
clearly needed to define accurately the beneficial effects of weight loss
on mortality.
5.5
Most studies on the quality of life of obese patients before and after
weight loss have been conducted on patients following surgery for
obesity, and all show dramatic improvements in the overall quality of
72
life. The SOS study in Sweden (27), for example, showed significant
improvements in social interaction, anxiety, depression and mental
well-being that were sustained for 2 years after surgery for obesity.
Although it is unclear whether these improvements will be seen with
modest weight loss following non-surgical intervention, Klem et al.
(28) recently reported that formerly obese subjects who had lost
weight through diet and/or exercise modification found their quality
of life to be substantially improved. While this is based on selfreporting by individuals who were maintaining weight losses of at
least 13.6kg for periods of over 1 year, it provides additional evidence
of the benefits of weight loss.
Dieting is often perceived to have untoward psychological effects,
including depression, nervousness and irritability. However, studies
have shown that weight loss is associated with a decrease in depression score, particularly when it is achieved by behaviour modification
(29, 30).
A dramatic example of how extremely overweight individuals perceive their disorder has been provided by studies of a group of severely obese patients before and after losing weight as a result of
gastric surgery (31, 32). Before surgery, all the patients felt unattractive and the great majority felt that people talked about them behind
their backs at work. They also felt that they had been discriminated
against when applying for jobs and treated disrespectfully by the
medical profession. After having achieved a weight loss of 50kg, all
the patients said that they would prefer to be deaf, dyslexic or diabetic
or to suffer from severe heart disease or acne than to return to their
previous weight. Given a hypothetical choice, they all preferred to be
of normal weight than have "a couple of million dollars" - a choice
that they made in less than a second.
5.7
Weight loss from "crash" dieting may result in acute attacks of gout.
However, for intentional and controlled weight loss resulting from
medical intervention, only two distinct hazards have emerged from a
variety of prospective studies:
Gallbladder disease. Women who lose 4-lOkg have a 44% increased risk of clinically relevant gallstone disease, and greater
weight loss increases this risk. Mobilization of cholesterol from
adipose tissue stores is increased during weight loss, so that the risk
of supersaturation of bile with cholesterol is greater than when
weight is stable. Premenopausal women are at particular risk
because of an estrogen-induced enhanced biliary secretion of
cholesterol.
73
Weight cycling
Weight cycling refers to the repeated loss and regain of weight that
can occur as a result of recurrent dieting. However, there is no standard definition of weight cycling so that comparison between different studies is difficult (36).
It has been suggested that weight cycling is associated with negative
health outcomes, makes future weight loss more difficult and results
in a decrease in lean-to-fat tissue ratio (37). However, the evidence is
conflicting; weight variability was associated with increased risk of
CVD and all-cause mortality in men, particularly in those who continued to smoke, but the association between weight change and death
was not seen in the heaviest men (38). Recently in the USA, the
National Task Force on the Prevention and Treatment of Obesity
(39) concluded that the evidence available at the time was that the
increased risk was not sufficient to outweigh the potential benefits of
moderate weight loss in obese patients.
5.9
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renin activity and plasma aldosterone levels in obese patients. New England
Journal of Medicine, 1981, 304:930-933.
14. Rissanen A et al. Treatment of hypertension in obese patients; efficacy and
feasibility of weight and salt reduction programs. Acta Medica
Scandinavica, 1985, 218:149-156.
75
15. Law MR, Frost CD, Wald NJ. By how much does dietary salt reduction
lower blood pressure? Ill- Analysis of data from trials of salt reduction.
British Medical Journal, 1991, 302:819-824.
16. Elliott Pet al. lntersalt revisited: further analyses of 24 hour sodium
excretion and blood pressure within and across populations. British Medical
Journal, 1996, 312:1249-1253.
17. Ferro-Luzzi A et al. Changing the Mediterranean diet: effects on blood
lipids. American Journal of Clinical Nutrition, 1984, 40:1027-1 037.
18. Puska P et al. Dietary fat and blood pressure: an intervention study on the
effects of a low-fat diet with two levels of polyunsaturated fat. Preventive
Medicine, 1985, 14:573-584.
19. Obesity in Scotland. Integrating prevention with weight management. A
national clinical guideline recommended for use in Scotland. Edinburgh,
Scottish Intercollegiate Guidelines Network, 1996.
20. Lean MEJ et al. Obesity, weight loss and prognosis in type 2 diabetes.
Diabetic Medicine, 1990, 7:228-233.
21. American Diabetes Association Position Statement. Diabetes mellitus and
exercise. Diabetes Care, 1995, 7:416-420.
22. Wareham NJ et al. Glucose tolerance has a continuous relationship with
total energy expenditure. Diabetologia, 1996, 39(Suppl. 1):A8.
23. Dattilo AM, Kris-Etherton PM. Effects of weight reduction on blood lipids
and lipoproteins: a meta-analysis. American Journal of Clinical Nutrition,
1992, 56:320-328.
24. Hankey CR et al. Weight loss improves established indices of ischaemic
heart disease risk. Proceedings of the Nutrition Society, 1995, 54(Pt 2):94A.
25. Kiddy DS et al. Improvement in endocrine and ovarian function during
dietary treatment of obese women with polycystic ovary syndrome. Clinical
Endocrinology, 1992, 36:1 05-111.
26. Pasquali R et al. Clinical and hormonal characteristics of obese
amenhorrheic hyperandrogenic women before and after weight loss. Journal
of Clinical Endocrinology and Metabolism, 1989, 68:173-179.
27. Sjostrom L, Narbro K, Sjostrom D. Costs and benefits when treating obesity.
International Journal of Obesity and Related Metabolic Disorders, 1995,
19(Suppl. 6):S9-S12.
28. Klem ML et al. A descriptive study of individuals successful at long-term
weight maintenance of substantial weight loss. American Journal of Clinical
Nutrition, 1997, 66:239-246.
29. Smoller JW, Wadden TA, Stunkard AJ. Dieting and depression: a critical
review. Journal of Psychosomatic Research, 1987, 31:429-440.
30. Kunesova M et al. Predictors of the weight loss in morbidly obese women:
one year follow up. International Journal of Obesity and Related Metabolic
Disorders, 1996, 20(Suppl. 4):59.
31. Rand CSW, MacGregor AMC. Morbidly obese patients' perceptions of
social discrimination before and after surgery for obesity. Southern Medical
Journal, 1990, 83:1390-1395.
76
32. Rand CSW, MacGregor AMC. Successful weight loss following obesity
surgery and the perceived liability of morbid obesity. International Journal of
Obesity, 1991, 15:577-579.
33. Langlois JA et al. Weight change between age 50 years and old age is
associated with risk of hip fracture in white women aged 67 years and
older. Archives of Internal Medicine, 1996, 156:989-994.
34. Compston JE et al. Effect of diet-induced weight loss on total body bone
mass. Clinical Science, 1992, 82:429-432.
35. Avenell A et al. Bone loss associated with a high fibre weight reduction diet
in postmenopausal women. European Journal of Clinical Nutrition, 1994,
48:561-566.
36. Jeffery RW. Does weight cycling present a health risk? American Journal of
Clinical Nutrition, 1996, 63(3 Suppi.):452S-455S.
37. Lissner L et al. Body weight variability in men: metabolic rate, health and
longevity. International Journal of Obesity, 1990, 14:373-383.
38. Blair SN et al. Body weight change, all-cause mortality and cause-specific
mortality in the Multiple Risk Factor Intervention Trial. Annals of Internal
Medicine, 1993, 119:749-757.
39. Weight cycling. National Task Force on the Prevention and Treatment of
Obesity. Journal of the American Medical Association, 1994, 272:11961202.
40. Rocchini AP et al. Blood pressure in obese adolescents: effect of weight
loss. Pediatrics, 1988, 82:16-23.
41. Knip M, Nuutinen 0. Long-term effects of weight reduction on serum lipids
and plasma insulin in obese children. American Journal of Clinical Nutrition,
1993, 57:490-493.
42. Vajro P et al. Persistent hyperaminotransferasemia resolving after weight
loss in obese children. Journal of Pediatrics, 1994, 125:239-241.
77
6.
6.1
Introduction
The economic costs of obesity have been assessed in several developed countries and are in the range 2-7% of total health care costs.
These are conservative estimates based on variable criteria but
clearly indicate that obesity represents one of the largest items of
expenditure in national health care budgets.
Although there have been no studies of the economic impact of
obesity in developing countries, the escalating economic burden of
adult NCDs in such countries has already been recognized by a
number of international agencies including WHO and the World
Bank. The real costs of therapy in developing countries exceed
those in developed countries because of the extra burden associated with the use of scarce foreign exchange to pay for imports of
expensive equipment and drugs, as well as the need for the specialized training of staff. In view of the existing burdens of endemic
deficiency disorders and infectious diseases, obesity prevention is
not only crucial but also the only sensible approach to planning
public health policies in developing countries.
Preliminary data suggest that a large proportion of the economic
costs of obesity can be avoided by efficient prevention or intervention strategies.
6.2
Cost-of-illness studies
The major criticism of cost-of-illness studies is that they can be misused. A cost-of-illness study may indicate that a disease is costly to
treat. It may also suggest that a disease has a high social cost relative
to other diseases or social problems, implying that society would
be relatively better off without it. While this is obviously true, it does
not mean that a higher priority should be given to treating that
disease. Treatment (or prevention) may be relatively ineffective or
expensive, so that priority-setting should be based on the relative
cost-effectiveness of interventions and not on the cost of the disease
alone. This criticism is best explained by Davey & Leeder (1):
" ... Instead of answering the question, 'Where should I put the next health
care dollar to achieve the greatest health gain?' cost-of-illness studies
provide information only about the burden of illness. They concentrate on
cost and say nothing about the effectiveness of treatment and value for
money invested."
and savings in health care resources could be made if effective interventions were available.
A further criticism concerns the focus of cost-of-illness studies on
direct health care costs and the indirect costs of lost production, less
emphasis being placed on the burden of disease, premature death and
reduced quality of life. Because these latter intangible costs are less
easy to measure in monetary terms, they tend to be ignored. Diseases
associated with high health care costs but relatively low morbidity and
mortality (such as dental disease) may therefore be seen as imposing
a far greater burden than other diseases associated with high costs in
terms of premature death and reduction in quality of life but low
health care costs (such as youth suicide).
The definition of health care incorporated in cost-of-illness studies
tends to be narrow and ignores many of the direct costs of disease
management and prevention, especially those arising outside the formal health care system. This is particularly true of obesity, as the
highest direct cost category is most likely to be the personal expenditure on weight-loss programmes incurred by overweight and obese
individuals. The impact of the narrow range of direct costs included in
studies is likely to vary across disease types and risk factors.
6.2.3 Steps in undertaking a cost-of-illness study
The following basic steps need to be taken in carrying out a cost-ofillness study on obesity-related disease where, in accordance with the
WHO criteria, overweight is defined as BMI 25-29.9 and obesity as
BMI ~ 30:
-
Population-attributable fraction
The epidemiological statistic needed to quantify the direct relationship between a risk factor of interest and a disease (and thus quantify
its associated economic costs) is the population-attributable fraction.
81
This has been defined as the proportion of total events (e.g. deaths or
morbidity) in a population that could be prevented if a particular risk
factor (e.g. obesity) could be eliminated.
The P AF reflects the overall impact of the morbidity and mortality
associated with a factor (e.g. obesity) in the specified population. It
can be interpreted from an etiological standpoint (causal outcomes
attributed to a particular risk factor) or from a prevention standpoint
(the maximum number of events that could be prevented). Many
epidemiologists use the concept of "preventable proportion" as a
useful generalization of the P AF concept.
Where only one category of exposure (e.g. obese or non-obese) is
concerned, P AF is given by:
PAP= p(RR-1)
1+ p(RR-1)
where p
RR
Ie/10
Table 6.1
Economic costs of obesity
Country
Year
Study
BMI
Estimated direct
costs
National
health
care costs
Australia
France
Netherlands
1989-1990
1992
1981-1989
>30
"?.27
>25
A$ 464 million
FF 12000 million
NLG 1 000 million
>2%
2%
4%
USA
1994
NHMRC (16)
Levy et al. ( 17)
Seidell &
Deerenberg ( 18)
Wolf & Colditz
>29
6.8%
( 19)
a
83
categories used and the epidemiological assumptions as to the relationship between obesity and disease. This makes it difficult to compare costs across countries and to extrapolate the results from one
country to another. The limited data available suggest that, as previously mentioned, some 2-7% of total health care expenditure in a
country may be directly attributable to overweight and/or obesity.
Australia
The cost of the excess use of medical care and associated costs due to
obesity in the Netherlands were estimated using the data on 58000
participants in the Health Interview Surveys carried out from 1981 to
1989 (18). The health care costs included those for consultations with
general practitioners and medical specialists, hospital admissions and
the use of prescribed drugs. Obese (BMI ?.30) and overweight (BMI
25-30) individuals were more likely to have consulted a general practitioner. The total general practitioner costs attributable to obesity/
overweight were equivalent to 3-4% of the country's total general
practitioner expenditure. For hospitalizations, the fraction attributable to obesity was 3% and for overweight 2%. The excess use of
medications by obese and overweight people, however, was very
striking: compared with the non-obese, obese individuals were 5 times
more likely to use diuretics and 2.5 times more likely to take drugs for
CVD. It was estimated from these data that the direct costs of overweight and obesity were about 4% of total health care costs in the
Netherlands. This is of the same order of magnitude as the health care
costs attributable to all forms of cancer.
While the study did not cover all potential cost categories relevant to
obesity, it was the first cost estimate to include the impact of overweight, and this category accounted for about 48% of the total costs
of excess weight gain.
United States of America
Methods other than cost-of-illness studies have been used to determine the economic impact of obesity-related diseases, e.g. studies on
the influence of obesity either on attainment of social class (see
below) or on pension and disability payments.
It is important to note that indirect costs of disease relate to the loss
In the SOS study (25) in Sweden, the frequency of long-term sickleave (over 6 months) was reported to be 1.4 and 2.4 times higher in
obese men and women, respectively, compared with the general
Swedish population. Similarly, the rate of premature disability pensions was reported to be increased by a factor of 1.5-2.8 among
participants in the study. The total loss of productivity due to obesity
was estimated to be about 7% of the total cost of losses of productivity due to sick-leave and disability pensions in Sweden.
Premature work disability
Although there have not been any comparable studies of the economic impact of obesity in developing countries, both WHO and the
World Bank have recently highlighted the increasing burden associated with the rapidly emerging adult NCDs in these countries (15, 27),
where they have now replaced infectious diseases as the leading cause
of death. In developing countries, about 50% of deaths in 1990 were
caused by NCDs, but by 2020 that proportion is expected to rise to
almost 77%. In 1990, some 42% of deaths were attributed to infectious and reproductive conditions, while by 2020 that proportion is
expected to decline to about 12%. In contrast, in developed countries
87% of deaths in 1990 were from NCDs and the proportion is expected to rise only slightly-to 90%-by 2020.
The treatment needs of the rapidly expanding urban populations and
increasingly affluent middle classes in developing countries are already overwhelming many medical services. Furthermore, as previously mentioned, the real costs of therapy associated with NCDs in
developing countries exceed those in developed countries; the need to
use scarce foreign exchange to pay for imports of expensive equipment and drugs and for the training of specialized staff creates an
extra burden.
In recent World Bank studies, e.g. in Chile (28), the burden of disease
has been expressed in terms of numbers of DALYs lost. NCDs account for a 5- and 9-fold greater rate of premature death than communicable diseases in men and women, respectively, and 10- and 5-fold
greater rates of disability. The numbers of DALYs lost in men are 15fold, and in women 20-fold, greater for NCDs than for infections. So
far, the burden of disease attributable to excess weight gain and
obesity has not been calculated, but cancers impose a substantial
burden as do NIDDM and CVD. There is thus a need in developing
countries to apply the new economic methods of determining the
proportion of these diseases attributable to excess weight gain so that
the impact of one of the principal contributors to NCDs can be
assessed.
6.3.4 Conclusions
prevalence of obesity
diet (1 kcal1h = 4.18 kJ). Subjects lost an average of 15.3 kg over the
12 weeks, but at 1-year follow-up had regained 9.0kg. The authors
estimated that the average saving in prescription costs per subject
over 1 year was US$ 442.80. While the study showed a significant
prescription cost saving, sample sizes were small and the energy intake associated with the weight-loss programme was very small. It
would thus be unwise to assume that these results would be reproduced under different conditions.
As an extension of a cost-of-obesity study discussed earlier in this
section (seep. 84), the NHMRC estimated the potential annual saving
to the Australian health care system that would result if the prevalence of obesity were reduced by 20% by the year 2000 (baseline
1989), as specified by the National Health Goals and Targets (30).
The method used in this study was to recalculate the P AF based on
the target prevalence of obesity (and on the assumption that relative
risk estimates remain constant) for each obesity-related disease. The
1989-1990 estimated cost for each obesity-related disease was then
multiplied by the change in P AF to estimate the potential annual
saving. The NHMRC estimated that an annual saving of A$ 59
million in health care expenditure and a potential 2300 life-years
could be gained if the obesity target was achieved.
While the NHMRC calculation shows the potential cost saving that
might be achieved if the target obesity prevalence were achieved, it
does not provide information on the public and private expenditure
that would be required to fund programmes to achieve this target.
The analysis therefore does not help decision-makers to decide
whether investing scarce community resources in preventing or treating overweight and obesity represents an efficient use of such resources. Such decisions should be based on an evaluation of the costs
and outcomes (effectiveness) of alternative interventions for the prevention and treatment of overweight and obesity.
6.4.3 Cost-effectiveness of obesity prevention and treatment
Few studies have addressed the economic evaluation of the prevention and treatment of overweight and obesity and, of these, most have
been concerned with treatment rather than primary prevention. A
limited number of studies on the cost-effectiveness of non-drug versus
drug treatment of hypertension have been conducted and have
included measurements of weight loss. In addition, a number of
studies have focused on the financial benefits of workplace fitness
programmes (including the benefit of weight loss) in reducing employee absenteeism, but the methods used in these studies have been
criticized (31, 32). Authors have sometimes overgeneralized and used
91
Table 6.2
Summary of the estimated cost-effectiveness of a range of interventions for the
prevention of NIDDMa
Intervention
1200
3500
4600
12300
saving
1600
saving
2600
saving
saving
saving
saving
800
2100
1200
2400
Media programme
saving
saving
a
b
mated effect of weight loss on all-cause mortality, and not just that
associated with NIDDM, the probable impact of a successful prevention programme on other risk factors (such as cholesterol or blood
pressure) has not been taken into account. In addition, the expected
savings in future health care costs relate to NIDDM only, ignoring
possible savings in the management of other obesity-related diseases.
For these reasons the results may well be conservative.
The authors of the study concluded that the prevention of NIDDM,
through appropriate interventions, can represent a highly efficient use
of community resources. Such programmes can achieve a substantial
improvement in health status at little cost or indeed with the possibility of a net saving in the use of health care resources.
Cost-effectiveness of commercial weight-loss programmes
period) of losing 1 kg. The diet programmes were divided into three
groups:
1. Medically supervised very-low-calorie diets (VLCDs) that provide
<800kcal1h/per day. 1
2. Nutrient-balance reduced-energy diet programmes (REDPs), the
client consuming 800-1200kcal1h/dayl (50% carbohydrate, 15-20%
protein, <30% fat).
3. Support groups that may or may not offer individual dietary advice
and act as a self-help programme with volunteer staff.
It was found that the cost of a 12-week commercial weight-loss
programme varied enormously, from US$ 2120 for the most expensive VLCD to US$ 108 for the least expensive REDP. The data are
summarized in Table 6.3.
94
1 kcal,h = 4.18kJ.
Table 6.3
Cost in US$ per kilogram of active weight loss (12 weeks)"
Initial weight
Programme type
80kg
136kg
Nutrient-balanced REDP:
Jenny Craig
Nutri-System
Registered dietitian
Weight Watchers
23.00
1900
15.00
2.50
13.50
12.00
9.00
1.50
VLCD programmes:
Health Management Resources (HMR)
Medifast
17.50
14.00
10.00
8.00
0.07
0.04
Support groups:
Taking Off Pounds Sensibly (TOPS)
a
ventions measured, the costs of the programmes might well have been
different.
Economic costs and benefits of obesity treatment in developing countries
No analyses have been made of the economic costs of obesity treatment in developing countries. However, other analyses of the costs of
health interventions show that prevention is more cost-effective than
treatment once disease is diagnosed. In Table 6.4, the costs of a
variety of public health packages (including education, information,
surveillance and monitoring) are compared with those of some primary care clinical services in developing countries where the major
needs are the treatment of trauma and infection. Low-income developing countries do not have the resources to provide anything other
than public health and essential clinical services. In middle-income
developing countries, the high costs of discretionary clinical services
(see Table 6.4) mean that the cost of dealing with chronic diseases
exceeds that of all other forms of health care. Thus, it would appear to
be more cost-effective for money spent on obesity and other NCDs to
95
Table 6.4
Allocation of public expenditure on health in developing countries, 1990
Type of
service
Allocation in
developing countries
(US$ per person
per year)b
Actual
Contents of health-related
packages
Cost per
DALY
(US$)
Proposed
Public health
package
25
Essential
clinical
services
10
25-75
13-15
>1000
21
21
Discretionary
clinical
servicesd
Total
a
b
c
d
weight gain in developing countries are not treated, and the demand
for medical and dietetic help is expected to rise rapidly. In addition,
limited resources will be diverted to pay for slimming diets and other
aids to weight loss.
In developing countries where NCD epidemics are emerging or accelerating, a large proportion of NCD deaths occur in the productive
middle years of life, at ages much younger than those seen in developed countries. The health burdens attributable to excess weight gain
in societies in transition are likely to be huge because of the absolute
numbers at risk, the large reduction in life expectancy and the fact
that the problem affects, in particular, individuals with a key role in
promoting economic development.
References
1. Davey PJ, Leeder SR. The cost of cost-of-illness studies. Medical Journal of
Australia, 1993, 158:583-584.
2. Perry IJ et al. Prospective study of risk factors for development of noninsulin-dependent diabetes in middle-aged British men. British Medical
Journal, 1995, 310:560-564.
who are less overweight and eat less fat. The Iowa Women's Health Study.
Cancer, 1995, 76:275-283.
10. Yong LC et al. Prospective study of relative weight and risk of breast
cancer: the Breast Cancer Detection Demonstration Project follow-up study,
1979 to 1987-89. American Journal of Epidemiology, 1996, 143:985-995.
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11. Giovannucci E et al. Physical activity, obesity and risk for colon cancer and
adenoma in men. Annals of Internal Medicine, 1995, 122:327-334.
12. Siega-Riz AM, Adair LS, Hobel CJ. Institute of Medicine maternal weight
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Hispanic population. Obstetrics and Gynecology, I 994, 84:565-573.
13. Spector TD, Hart DJ, Doyle DV. Incidence and progression of osteoarthritis
in women with unilateral knee disease in the general population: the effect
of obesity. Annals of the Rheumatic Diseases, I 994, 53:565-568.
14. Voigt LF et al. Smoking, obesity, alcohol consumption, and the risk of
rheumatoid arthritis. Epidemiology, I 994, 5:525-532.
15. Murray CJL, Lopez AD, eds. The global burden of disease. Boston, MA,
Harvard University Press, 1996.
16. National Health and Medical Research Council. Economic issues in the
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17. Levy E et al. The economic cost of obesity: the French situation.
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19:788-792.
18. Seidell J, Deerenberg I. Obesity in Europe- prevalence and
consequences for the use of medical care. PharmacoEconomics, 1994,
5(Suppl. I ):38-44.
19. Wolf AM, Colditz GA. The costs of obesity: the U.S. perspective.
PharmacoEconomics, 1994, 5:34-37.
20. Colditz GA. Economic costs of obesity. American Journal of Clinical
Nutrition, 1992, 55(2 Supp1.):503S-507S.
21. Tipping the scales. Melbourne, The Consumer Advocacy and Financial
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22. Hakkinen U. The production of health and the demand for health care in
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23. Sonne-Holm S, Sorensen Tl. Prospective study of attainment of social class
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and education. British Medical Journal, 1986, 292:586-589.
24. Gortmaker SL et al. Social and economic consequences of overweight in
adolescence and young adulthood. New England Journal of Medicine,
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25. Sj6str6m L, Narbro K, Sjbstrom D. Costs and benefits when treating obesity.
International Journal of Obesity and Related Metabolic Disorders, 1995,
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26. Rissanen A et al. Risk of disability and mortality due to overweight in a
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28. Chile: the adult health policy challenge. Washington, DC, World Bank, 1995
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99
PART Ill
Understanding how
overweight and
obesity develop
100
7.
7.1
Introduction
In simple terms, obesity is a consequence of an energy imbalance energy intake exceeds energy expenditure over a considerable period.
Many complex and diverse factors can give rise to a positive energy
balance, but it is the interaction between a number of these factors,
rather than the influence of any single factor, that is thought to be
responsible. In contrast to the widely held perception among the
public and parts of the scientific and medical communities, it is clear
that obesity is not simply a result of overindulgence in highly palatable foods, or of a lack of physical activity.
The various influences on energy intake and expenditure that are
considered to be important in weight gain and the development of
obesity are considered below. Section 7.2 gives an overview of the
fundamental principles of energy balance, the physiological regulation of body weight and the dynamics of weight gain. Section 7.3
examines the role of dietary factors and physical activity patterns in
weight gain. Section 7.4 discusses the multitude of environmental and
societal forces that adversely affect food intake and physical activity
patterns, and may thus overwhelm the normal regulatory processes
that control the long-term energy balance. Finally, section 7.5 reviews
the various genetic, physiological or medical factors that can determine an individual's susceptibility to those forces and that put that
person at higher risk of weight gain and obesity.
The following should be noted:
Obesity can result from a minor energy imbalance that leads to a
gradual but persistent weight gain over a considerable period. Once
the obese state is established, physiological processes tend to maintain the new weight.
Body weight is primarily regulated by a series of physiological
processes but is also influenced by external societal and cognitive
factors.
Recent epidemiological trends in obesity indicate that the primary
cause of the global obesity problem lies in environmental and
behavioural changes. The rapid increase in obesity rates has occurred in too short a time for there to have been significant genetic
changes within populations.
The increasing proportion of fat and the increased energy density
of the diet, together with reductions in the level of physical activity
101
baic~nce
Figure 7.1
Influences on energy balance and weight gain (energy regulation)
'C."'"'{
lndividuaV
biological
susceptibility
.....................................................................
The diagram shows the fundamental principles of energy balance and regulation. A positive
energy balance occurs when energy intake is greater than energy expenditure, and promotes
weight gain. Conversely, a negative energy balance promotes a decrease in body fat stores and
weight loss. Body weight is regulated by a series of physiological processes that have the
capacity to maintain weight within a relatively narrow range (stable weight). lt is thought that the
body exerts a stronger defence against undernutrition and weight loss than it does against
overconsumption and weight gain. However, powerful societal and environmental forces
influence energy intake and expenditure, and may overwhelm the above-mentioned physiological processes. The susceptibility of individuals to these forces is affected by genetic and other
biological factors, such as sex, age and hormonal activities, over which they have little or no
control. Dietary factors and physical activity patterns are considered to be the modifiable
intermediate factors through which the forces that promote weight gain act.
TEF =thermic effect of food; BMR = basal metabolic rate; CHO = carbohydrate.
103
Table 7.1
Energy content of macronutrients
Macronutrient
Fat
Alcohol
Protein
Carbohydrate
Energy contribution
(kcal,h/g)
(kJ/g)
37
29
4
4
17
16
is only when there has been a positive energy balance for a considerable period that obesity is likely to develop.
Energy intake
Total energy intake refers to all energy consumed as food and drink
that can be metabolized inside the body. Table 7.1 shows the energy
content of the constituent macronutrients present in food and drink.
Fat provides the most energy per unit weight, and carbohydrate and
protein the least. Fibre undergoes bacterial degradation in the large
intestine to produce volatile fatty acids that are then absorbed and
used as energy. The size of the energy contribution from fibre is
thought to be 6.3 kJ/g (1.5 kcal1h/g) (1).
Energy expenditure
Societal and cognitive factors can influence the control of body weight
to a certain extent, but it is a series of physiological processes that are
primarily responsible for body weight regulation. In traditional societies, where people tend to be more physically active, and provided
that food supplies are not limited, few adults are either underweight
or overweight despite the interaction of seasonal cycles of work,
festivities, individual susceptibilities to obesity for physiological or
genetic reasons, and the wide range of varying physical demands
within a society. Such physiological mechanisms constitute a fundamentally important biological process that can be observed throughout the animal kingdom. It is thought that the body exerts a stronger
defence against undernutrition and weight loss than it does against
overconsumption and weight gain (3).
The physiological mechanisms responsible for body weight regulation
are incompletely understood. However, there is increasing evidence
of a range of signalling mechanisms within the intestine, the adipose
tissue and brain, and perhaps within other tissues, that sense the
inflow of dietary nutrients, their distribution and metabolism and/or
storage. These mechanisms are coordinated within the brain and lead
to changes in eating, in physical activity and in body metabolism so
that body energy stores are maintained. The recent discovery of the
hormone leptin, which is secreted by adipocytes in proportion to their
triglyceride stores and binds with receptors in the hypothalamus,
provides interesting insights into possible regulatory signal systems
that act to maintain the energy balance. However, much remains to
be elucidated about such systems, some of which are illustrated in
Fig. 7.2.
7.2.3 Dynamics of weight gain
Despite the extensive physiological regulation of body weight outlined above, a positive energy balance can lead to weight gain if it
persists in the long term. The initiation of a chronic positive energy
balance is due to an increase in energy intake relative to requirements, either as a result of an increase in total energy intake, a
decrease in total energy expenditure, or a combination of the two.
Currently there is little information about the fluctuations in energy
balance that lead to weight gain and obesity. It is possible that large
deviations from energy balance at regular intervals may contribute to
weight gain, but it is believed that a small consistent deviation over a
long period is also capable of producing large increases in body
weight.
105
Figure 7.2
Physiological processes involved in body weight regulation
Afferent signals
Controller
(brain)
Efferent
systems
Controlled system
(nutrient partitioning)
Diet
composition
Autonomic
nervous system
Hormonal
systems
Protein
----J
Body fat
Physical activity
Genetic factors
WH098268
The diagram shows the interaction between the different mechanisms that affect energy and
body weight regulation within individuals. The brain integrates an array of afferent signals
(nutrient, metabolic, hormonal and neuronal) and responds by inducing changes in food intake,
autonomic nervous system activity, hormonal responses or spontaneous physical activity. The
different components then directly or indirectly determine the proportion of dietary energy
deposited as protein rather than fat
Fig. 7.3 shows that the process of gaining weight can be divided into
the following three phases:
The preobese static phase, when the individual is in long-term energy balance and weight remains constant.
The dynamic phase, during which the individual gains weight as a
result of energy intake exceeding energy expenditure over a prolonged period.
The obese static phase, when energy balance is regained but weight
is now higher than during the preobese static phase.
The dynamic phase can last for several years and often involves
considerable fluctuations in weight (weight cycling) as a result of
conscious efforts by the individual to return to a lower weight. However, in the absence of intervention, the difference between energy
intake and energy expenditure progressively diminishes. This is due
to an increase in BMR as a result of the larger fat-free mass (including
that in the expanded adipose tissue) as well as to an additional energy
106
Figure 7.3
Effect on energy expenditure, energy balance and body weight of an increase in
energy intake relative to requirements
Increased energy intake relative to requirements
Equilibrium
IN
OUT
New equilibrium
IN
OUT
IN
OUT
IN
OUT
Fat mass
Fat-free mass
Time
WH098284
A persistent increase in energy intake above requirements will lead to a gradual gain in body
weight. However, the size of the energy imbalance progressively diminishes as weight is
gained, because of an increase in metabolism associated with the larger fat-free mass and the
expanded adipose tissue. A new higher equilibrium weight is eventually established that is
again defended by physiological mechanisms. Thus, it is harder to lose the weight gained than
it is to experience a second cycle of increasing body weight should, for example, a fall in
physical activity occur at the same time as a further period of prolonged positive energy
balance.
a
Adapted, with permission, from: Schutz Y. Macronutrients and energy balance in obesity.
Metabolism, 1995, 4(9 Suppl. 3) 7-11 (reference 4).
cost of activity imposed by the extra weight (5). There may also be an
increase in resting metabolic rate (RMR) with overfeeding (6).
Once the obese static phase is established, the new weight appears to
be defended. This can best be shown by the response of obese individuals to underfeeding; they show a fall in metabolic rate as the body
recognizes the loss of energy (7) and an unconscious physiologically
driven increase in energy intake (8).
7.2.4 Implications for public health
7.3
Macronutrient composition
There is no clear evidence to suggest that high intakes of sugar overwhelm the appetite-control signals in the same manner as fat. However, there is some indication from short-term feeding trials that ad
libitum low-fat high-complex-carbohydrate diets of low energy density induce weight loss. This does not occur on energy-dense diets,
regardless of whether the energy density has been increased by modifying the fat content or the sugar content of the diet (12). Further
studies are required before any conclusions can be drawn from this
work.
Energy storage and macronutrient balance. The macronutrient composition of the diet also influences the extent to which excess energy is
stored, depending on the storage capacity within the body of the
macronutrients concerned, those macronutrients with a low storage
capacity within the body being preferentially oxidized when intakes
exceed requirements:
Sweetness is one of the most powerful, easily recognized and pleasurable tastes, so that many foods are sweetened in order to increase
their palatability and consumption. The consumption of sugars does,
however, lead to a subsequent suppression of energy intake by an
amount roughly equivalent to the amount provided by the sugars
(21). Nevertheless, sweetened foods of high fat content are expected
to be conducive to excess energy consumption since palatability is
enhanced both by sweetness and mouth-feel, and fat has only a small
suppressive effect on appetite and intake. A preference for sweet-fat
mixtures has been observed in obese women and may be a factor in
promoting excess energy consumption (22).
Overview of macronutrient influence on body weight regulation. Table 7.2
summarizes the main characteristics of the macronutrients. Fat appears to be the key macronutrient that undermines the body's weight
regulatory systems since it is very poorly regulated at the level of both
consumption and oxidation. There is currently no consensus regarding the role of sugar intake on body weight regulation but there is
some concern that the overconsumption of sweet-fat foods may be a
110
Table 7.2
Characteristics of macronutrients
Characteristic
Protein
Carbohydrate
Fat
High
High
Low
Low
Low
Yes
Intermediate
High
High
Low
Low
Yes
Low
Low
High
High
High
No
Excellent
Excellent
Poor
Research on eating patterns and health has focused mainly on fluctuations in blood glucose and blood lipid concentrations throughout the day, particularly in the context of the control
of NIDDM. There does appear to be some advantage in nibbling
versus gorging under isocaloric conditions from the point of view of
glycaemic control and hypertriglyceridaemia (23). However, in at
least one controlled study, there was no effect of meal patterns on
energy metabolism and energy balance (24).
Daily eating pattern.
Under free-living conditions, meal patterns vary widely across populations and cultures. Regular (high-fat) snacking has been associated
with increased overall dietary intake in affluent societies, but this
conclusion remains controversial (25). Other evidence from affluent
societies suggests that dietary restraint and slimming leads to skipping
breakfast and that this may result in overconsumption later in the day
(26). Some people exhibit additional eating during the night, possibly
as part of a night-eating syndrome (27) that is associated with obesity,
although the mechanism underlying this association is not known.
Recently, in a study in obese people trying to lose weight, it was found
that the prognosis of weight loss was better in women who ate more
and smaller meals than in those who ate fewer but larger meals. 1
1
Astrup A. ed. Food and eating habits, 1996. Background paper prepared by the Food
and Eating Habits subgroup of the International Obesity Task Force.
111
Increased energy expenditure is an intrinsic feature of physical activity and exercise. Energy requirements increase from basal levels
112
Box 7.1
Physical activity
Sport defined differently around the world but usually implies a form
of physical activity that involves competition. lt may also embrace
general exercise and a specific occupation.
Box 7.2
Physical activity levels
PAL
1.4
1.55-1.60
;:::1.75
Activity ratio"
4-5
45 minutes
6-7
30 minutes
10-12
Activity
Brisk walk (6 km/h), canoeing
(5km/h); cycling (12km/h),
gardening; baseball; volleyball
Cross-country hiking; cycling
(15km/h); skating (14km/h); water
skiing; dancing; snow-shoeing
Any vigorous activity, e.g. football;
hockey; running (13 km/h); rugby;
handball; basketball (competition)
resting levels for some time after exercise ceases. This metabolic
response is called the "excess post-exercise oxygen consumption"
(EPOC) and is due to the need to restore energy reserves, especially
glycogen levels in liver and muscles. Compared with the energy cost
of exercise itself, however, the contribution of EPOC is likely to be
modest. In a recent study, it was estimated that, after 2 hours' exercising at a moderate intensity, it accounted for an extra 200kJ/day
114
One of the most important adaptations to regular exercise is the increased capacity to use fat
Regular physical activity and substrate balance.
115
the duration of the activity, despite the fact that the proportion of fat
in the mixture of fuel oxidized for muscular contraction may decrease
at higher intensities. It should also be kept in mind that fat is oxidized
not only during the activity but also in the recovery period.
Impact of physical activity on food intake and preference
(mean PAL 1.6) (49). It has been suggested, therefore, that people
should remain physically active throughout life and sustain a PAL of
1.75 or more in order to avoid excessive weight gain. Sedentary people
living or working in cities typically have a PAL of only 1.55-1.60, and
PALs in industrialized societies are drifting downwards.
People who make extensive and increasing use of motorized transport, automated work and sedentary leisure pursuits, may find it
difficult to attain PAL levels at or above 1.75 simply by increasing
activity during "leisure time". This is illustrated by the calculations of
Ferro-Luzzi & Martino (49), who showed that, for an average 70-kg
adult male, increasing a PAL of 1.58 to one of about 1.70 involves an
average of 20 minutes a day of vigorous exercise, such as running or
circuit training at an activity ratio of 11 (a level of activity achievable
only by a physically fit person), or else 1 hour of extra walking every
day. Increasing a PAL of 1.58 to one of 1.76 requires approximately 1
hour and 40 minutes of extra walking (at 4km/h) per day (Fig. 7.4). As
these activity requirements are additional to a 24-minute period of
"active leisure" (12 minutes of sports and 12 minutes of walking)
already required for a PAL of 1.58, it follows that urban sedentary
populations are likely to attain a PAL of 1.75 or more only if supported by vigorous national policies that encourage physical activity.
For example, these should encourage children to be active at play and
school, and should create environments in which walking and cycling
become the most common means of travel to work and for short
JOUrneys.
7.4
Figure 7.4
Active leisure required to achieve an overall mean PAL of 1.76
1400
1300
Domestic work
(BRM X 2.82)
Domestic work
(BRM X 2.82)
Gainful work
(BMRx 1.60)
Gainful work
(BMRx 1.60)
Active leisure*
(BMR x4.20)
Passive leisure
(BMR X 2.29)
1200
1100
1000
900
>ro
800
700
"':2
600
500
400
Personal needs
(BMR X 1.06)
300
200
100
0
PAL
1.58
12 minutes
*Active leisure (walking time)
1.76
111 minutes
This model of the nature, duration and timing of active leisure required to achieve an overall
mean PAL of 1. 76 is based on the activity profile of the average Italian adult male, aged 30-60
years (60). He is assumed to weigh 70 kg and to have a predicted BMR of 1690 kcal,h/day. He
is sedentary, being employed in a light-activity job (BMR factor= 1.60 (61)), and he spends
only 24 minutes per day in active leisure (made up of 12 minutes' sports and 12 minutes'
walking) at an overall BMR factor of 5.0. The other 252 minutes are spent in passive leisure
(BMR factor 1.94). Increasing his daily walking time (speed 4 km/h, BMR factor 4.0) to 111
minutes raises his daily PAL to 1.76. The extra 99 minutes of walking time have been taken
from the 252 minutes of passive leisure time; more specifically, it has been assumed that he
would replace all the time spent watching television (90 minutes) and 9 minutes spent reading
by walking.
a
Adapted from reference 49 with the permission of the publisher. Copyright John Wiley & Sons
Ltd.
Most adults who still have a "traditional" lifestyle appear to gain little
or no weight with age. Anthropometric studies have reported an
absence of obesity in the few remaining hunter-gatherer populations
of the world, since energy expenditure is generally high and food
supplies are scarce in certain periods of the year (70). For the majority
of the world's population, however, the process of "modernization"
has had a profound effect on the environment and on lifestyles over
the last 50-60 years.
Food is now more abundant and the overall energy demand of modern life has dropped appreciably. These changes have subsequently
been associated with dramatic increases in obesity rates. Indeed,
Trowell & Burkitt, who carried out 15 case-studies of epidemiological
120
Table 7.3
Examples of energy-saving activity patterns in modern societies
Transport
In the home
In the workplace
Public places
Sedentary pursuits
Urban residence
groups, in the last decade it has become clear that obesity is increasingly being seen in much younger age groups, e.g. in children and
adolescents. Trend or longitudinal data generally indicate that steady
increases in the rates of obesity are greater in urban areas (72).
However, a recent report from Samoa noted a dramatic increase in
obesity prevalence of 297% in men and 115% in women in a rural
community (73). This was clearly apparent even in the 25-34-year age
group in both sexes.
New World syndrome. Obesity can be seen as the first wave of a defined
cluster of NCDs now observed in both developed and developing
countries. This has been called the "New World syndrome" (74) and
is already creating an enormous socioeconomic and public health
burden in poorer countries. High rates of obesity, NIDDM, hypertension, dyslipidaemia and CVD, coupled with cigarette smoking and
alcohol abuse, are closely associated with the modernization/acculturation process and increasing affluence. The New World
syndrome is responsible for disproportionately high levels of morbidity and mortality in newly industrialized countries, including eastern Europe, as well as among the ethnic minorities and the
disadvantaged in developed countries (74). Thus, while obesity is
viewed by health professionals from a medical perspective, it also
needs to be recognized as a symptom of a much larger global social
problem.
Increasing urbanization
In industrialized societies, an increasing number of women are entering the job market or are returning to full- or part-time paid employment within a few years of childbirth. They still tend to take
responsibility for the health and well-being of the family but less and
less for the more time- and energy-consuming domestic chores concerned with cleaning and the preparation and serving of food.
Going out to work has given women greater economic influence,
especially over domestic purchases, and has contributed to the demand for convenience foods and labour-saving devices such as the
microwave oven. People in paid employment tend to spend less time
on shopping, cooking and other household tasks, so that the demand
for "convenience" food products has increased. People may no longer
have the time, energy, motivation or skills to prepare food from the
basic ingredients. In the USA, the percentage of food dollars spent on
eating outside the home increased by about 40% between 1980 and
1990 (79).
Changes in social structures
Food and food products are now commodities that are produced,
traded and sold for profit in a market that is no longer largely local but
increasingly global. Foods are less often seen as a matter of life and
death, or of religious or cultural significance. Manufacturers and retailers seek to minimize uncertainties and costs, and to maximize
returns. Competition is intense, both within and outside areas where
these manufacturers and retailers are operating (80).
Large companies have expanded to control ever-increasing shares of
trade in agriculture, manufacturing and retailing, and smaller farms
and shops are being squeezed out of business (81). The effects of the
debt crisis in the developing countries, the collapse of communism in
eastern Europe and the former Soviet Union, and the dominance of
free-market ideologies are promoting globalization and the development of market economies throughout the world, drawing even the
most isolated self-supporting peasants into a global market (63). The
concentration of food supply in the hands of a small number of
multinational companies reduces their responsiveness to consumer or
government pressure, and increases their influence on government
policy (82).
7.4.2 Variation within societies
Kingdom and the USA all showed that the proportion of obese men
and women was higher among those of a lower educational level (87,
88). The observed inverse relationship between education and body
weight may be partly attributed to the fact that individuals of higher
educational level are more likely to follow dietary recommendations
and adopt other risk-avoidance behaviours than those of low educational attainment (89). In the USA, a trend has been emerging among
the better educated sections of the population to adopt and adhere to
dietary guidelines and other "healthy lifestyles" (78). Unfortunately,
little is known about the relationship between education level and
obesity in developing countries except that urban adults are more
highly educated than those from rural areas.
The benefit of nutritional knowledge per se appears to be limited.
Surveys indicate that, although some people know what constitutes a
healthy diet, they prefer in practice to consume a relatively unhealthy
one (90). Obesity rates continue to climb, despite the increased frequency of dieting among obese people, suggesting that knowledge
and frequent attempts to slim are insufficient for successful weight
control. 1 However, without these widespread attempts to control
body weight, the prevalence of obesity in industrialized countries
might be much higher.
7.4.3 Cultural influences
Culture affects both food intake and physical activity patterns, although the "cultural attributes" responsible are not well characterized and accurately measured at present. Cultural behaviours and
beliefs are learned in childhood, are often deeply held, and are seldom questioned by adults, who pass them on to their offspring. Attitudes and beliefs may change over time, however, as shown by the
expectations in industrialized countries of body weight and shape that
appear to be of particular importance in determining people's
behaviour. Substantial differences in obesity prevalence between
relatively affluent populations indicate that cultural values and traditions may mediate or moderate the effects of affluence on obesity
rates.
1
126
Westenhoefer J. In: Social and cultural issues of obesity, 1996. Background paper
prepared by Social and Cultural subgroup of the International Obesity Task Force.
127
128
Hill AJ. In: Social and cultural issues of obesity, 1996. Background paper prepared by
Social and Cultural subgroup of the International Obesity Task Force.
Astrup A, ed. Food and eating habits, 1996. Background paper prepared by Food and
Eating Habits subgroup of the International Obesity Task Force.
129
Many governments
have failed to respond to the changing food supply by laying down or
amending food regulations governing food quality and safety, and the
labelling and advertising of foods. This has led to a situation in which
consumers are at risk of being badly informed or confused by poor
labelling or the unregulated marketing of foods. A recent report by
Consumers International (102) has shown that, even when regulations governing marketing and advertising exist, they are often not
enforced so that compliance with them is poor.
Regulation of food quality, advertising and labelling.
Food production policies. Economic development and increasing involvement in free markets often result in the abandonment by governments of a food production policy based on small regional food
producers and the adoption instead of one that involves large-scale or
centralized farming. Such policies often increase the movement of
people from rural areas to towns and cities and can result in a loss of
food diversity and of the production of traditional foodstuffs in favour
of the wide-scale production of cash crops for export markets.
130
Technological
advances in cultivating, preserving, producing, transporting and storing foods have increased the year-round availability of a wider variety
of foods to a larger number of people. The continuing globalization of
these processes means that such trends in food availability are spreading from industrialized countries to developing ones.
Advances in food technology and product development.
Advances in food technology have also contributed to the consumption of diets increasingly dependent on processed foods. It is now
possible to produce food products having almost any variety of taste,
textural quality and nutrient content. In fact, food characteristics are
often manipulated to such an extent that it is difficult for individuals
to associate visual, textural or taste cues with the energy content of
meals. This is especially important given the increasing trend towards
prepackaged foods and the concomitant decline in the use of natural
and basic ingredients in food preparation in the home. 1 Consumers
are losing control over the preparation of the foods that they eat,
and food composition is increasingly being placed in the hands of
manufacturers.
In order to survive in the modern competitive market economies,
businesses cannot stand still but need to grow and maintain or increase profits for shareholders. If this cannot be done by increasing
sales of basic foodstuffs to those who can afford to buy them, it can be
done by turning basic foodstuffs into other, more expensive products
(i.e. processed, prepackaged foods) (63).
Fast foods. Although it can be argued that "fast foods" have been
available for centuries, such foods tended to be those of traditional
diet and culture. Today, fast foods and snacks tend to be universal in
nature, are often provided by large multinational corporations, and
are high in fat, low in complex carbohydrates, and energy-dense
(105). They may not be entirely satisfying and are often used as
regular additions to the diet instead of being consumed as an occasional meal or treat. 2 Furthermore, beverages containing substantial
amounts of sugar or alcohol are often consumed as part of a fast-food
meal.
1
Buisson OH. Consumer food choices for the 2000s- the impact of social and
marketing trends. Paper presented at the CSIRO Food Industry Conference, Adelaide,
Australia, 1992.
Astrup A, ed. Food and eating habits, 1996. Background paper prepared by Food and
Eating Habits subgroup of the International Obesity Task Force.
131
Modern fast foods have proliferated rapidly, and are widely available
and intensively advertised. In 1991, it was reported that fast foods
accounted for 19% of the global consumer catering market, then
worth US$ 730000 million, and that their market share was expected
to grow to 25% by 2000. In the USA, the market for fast foods was
worth US$ 78000 million in 1992 (106), and more than 200 people are
served a hamburger every second of the day. Greater availability has
been achieved by increasing the number of outlets and the opportunities to eat outside the home; the number of fast-food outlets in the
United Kingdom doubled in the 10 years between 1984 and 1993,
while the number of restaurants and cafes remained the same (107).
Direct evidence that increased consumption of fast foods leads to
overweight and obesity is lacking. However, it is widely perceived that
this is the case and that obesity has increased in industrialized societies as families turn away from home-prepared meals and consume
more fast or take-away foods. The roles of the media and of the
consumer in this process are considered below.
Marketing and advertising. The commercialization of food manufacturing and retail outlets has encouraged enthusiastic marketing.
Larger portion sizes give the consumer an impression of "better
value" for money, and marketing strategies such as "eat all you can
for X dollars" represent an encouragement to eat beyond natural
biological limits. Furthermore, these foods and outlets are backed
by substantial advertising campaigns that, in stark contrast to public health or nutrition campaigns, are extremely persuasive and
successful. 1
The media
The media, including television, radio and print, play a major role in
disseminating information in modern consumer societies. They are
part of informal education, and both reflect and influence public
attitudes. However, far more money has been spent on promoting
high-fat/energy-dense foods than on promoting healthier foods. For
example, 86.2 million was spent on promoting chocolate confectionery in the United Kingdom in 1992 compared with only 4 million
spent on advertising fresh fruit, vegetables and nuts (108).
The media provide information on new and existing foods to consumers and have a pervasive influence on food choice; they have
clearly been influential in changing dietary patterns in recent decades.
1
132
Astrup A, ed. Food and eating habits, 1996. Background paper prepared by Food and
Eating Habits subgroup of the International Obesity Task Force.
Individual/biological susceptibility
Furthermore, no two obese individuals are the same; there are differences in both the degree and the regional distribution of excess body
fat as well as in the fat topography response of individuals to factors
that promote weight gain. Such differences are due not only to genetic
variation but also to the prior experiences and environments to which
the individuals have been exposed. The evidence for this conclusion
has been carefully reviewed (115). However, considerable uncertainty remains as to the genes and mutations involved, and how they
operate and interact to enhance the susceptibility of some individuals
to obesity.
The evidence for a role of genetic, biological and other factors in
determining the susceptibility of individuals to weight gain and obesity is briefly discussed here.
7.5.1 Genetic susceptibility
If the heritability estimates are correct- and the evidence for this is
quite strong - the genes are exerting their influence on body mass
and body fat as a result of DNA sequence variation either in the
coding sequence of the genes or in the segments that affect gene
expression. It is obvious that most of the genes contributing to obesity
do not qualify as necessary genes, i.e. genes that cause obesity whenever one or two copies of the defective allele are present. Indeed, the
135
genetic susceptibility seems to be rather one caused by genes associated with an increase in the proneness to gain weight over time or,
alternatively, by the absence of genetic influences that protect against
the development of a positive energy balance. In general, such genes
exert smaller effects on the phenotype than necessary genes-a situation that makes the identification of these genes and of the responsible mutations much more difficult. Nonetheless, even though the
genetic effect associated with the risk of obesity appears to be of the
multigenic type, there is some indirect evidence to support the notion
that one or a few genes may play a more important role. In other
words, obesity is a truly complex multifactorial phenotype with a
genetic component that includes both polygenic and major gene
effects.
A series of studies reported over the past several years strongly
supports the view that many genes are involved in causing susceptibility to obesity. Several types of research have been used to identify
these genes and the specific DNA sequence variation responsible for
the increase in risk of becoming obese. The evidence accumulated so
far has recently been reviewed (124) and provides statistical or experimental support for a role for about 70 genes, loci or markers. Many
more years of research will be needed before the important genes and
critical mutations are finally identified for both excess body fat content and upper body and abdominal fat accumulation.
Possible mechanisms whereby genetic susceptibility may operate
include:
Low RMR: e.g. studies in the Pima Indians have shown RMR
clusters in families and that those with lower RMR have a greater
risk of gaining lOkg in the following 5 years (125, 126).
Low rate of lipid oxidation: e.g. a low ratio of fat to carbohydrate
oxidation under standardized conditions is a risk factor for subsequent weight gain (18, 127).
Low fat-free mass: a low fat-free mass for a given body mass is a risk
factor for subsequent weight gain as it tends to depress the level of
RMR, thus favouring a positive energy balance.
Poor appetite control: e.g. if satiety is reached at a high level of
energy intake, the net result is likely to be a positive energy balance
and weight gain. Here, many genes and molecules are currently
under investigation. For instance, leptin, the hormone product of
the ob or leptin gene, is an important satiety factor secreted by the
adipose tissue in humans. An anomaly in the leptin receptor gene
may be associated with leptin resistance in humans. However, the
136
Table 7.4
Some factors involved in the development of obesity thought to be genetically
modulated
Macron utrient-related:
adipose tissue lipolysis
adipose tissue and muscle lipoprotein lipase (LPL) activity
muscle composition and oxidative potential
free fatty acids and ~-receptor activities in adipose tissue
capacities for fat and carbohydrate oxidation (respiratory quotient)
dietary fat preferences
appetite regulation
Energy expenditure:
metabolic rate
thermogenic response to food
pattern of energy usage (nutrient partitioning)
propensity for spontaneous physical activity
Hormonal:
insulin sensitivity
growth hormone status
leptin action
for carbohydrate before puberty while males prefer protein. However, after puberty, both males and females display a marked increase
in appetite for fat in response to changes in the gonadal steroid levels.
This rise in fat appetite occurs much earlier and to a greater extent in
females (128).
Females have a tendency to channel extra energy into fat storage
while males use more of this energy for protein synthesis. This pattern
of energy usage, or "nutrient partitioning", in females contributes to
further positive energy balance and fat deposition for two reasons.
First, the storage of fat is far more energy-efficient than that of protein, and second, it will lead to a lowering of the lean-to-fat tissue ratio
with the result that RMR does not increase at the same rate as body
mass.
Ethnicity
Ethnic groups in many industrialized countries appear to be especially susceptible to the development of obesity and its complications.
Evidence suggests that this may be due to a genetic predisposition to
obesity that only becomes apparent when such groups are exposed
to a more affluent lifestyle. This is demonstrated graphically by the
following:
Table 7.5
Critical periods for the development of obesity
Critical period
Prenatal
Adiposity rebound
(5-7 years)
Adolescence
Early adulthood
Pregnancy
Menopause
Table 7.6
Drugs that may promote weight gain
Drug
Depression
NIDDM
Hypertension
Contraception
Various diseases
NIDDM
Allergy, hay fever
Epilepsy
Psychosis
Migraine headache
The use of the drugs listed in Table 7.6 can promote weight gain.
Adults on long-term corticosteroid therapy for rheumatoid arthritis
may be at particular risk of weight gain, since the side-effects of the
drug exacerbate the effects of limited physical activity.
Disease states
Astrup A, ed. Food and eating habits, 1996. Background paper prepared by Food and
Eating Habits subgroup of the International Obesity Task Force.
141
can cause weight gain. However, these are extremely rare causes of
obesity, accounting for only a very small proportion of obesity in the
population.
Major reduction in activity
In some individuals, a major reduction in activity without a compensatory decrease in habitual energy intake may be the major cause of
increased adiposity. Examples include the weight gain often observed
in elite athletes when they retire, in young people who sustain sports
injuries, in young people in wheelchairs after accidents or in others
who develop arthritis.
Changes in social and environmental circumstances
Marriage (159), the birth of a child, a new job and climate change can
all lead to undesirable changes in eating patterns and consequent
weight gain.
7.6
Weight loss
References
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150
152
PART IV
153
8.
8.1
Introduction
emphasis on thinness has been accompanied by an increased prevalence of eating disorders such as anorexia nervosa and bulimia.
Interventions aimed at obesity prevention or management should
therefore be carefully designed to avoid precipitating the development of eating disorders associated with undue fear of fatness,
especially in young adolescent girls. Such interventions should also
discourage other unhealthy behaviours, e.g. cigarette smoking, that
may be adopted in the belief that they will prevent weight gain.
This section is concerned with the principles underlying prevention
and management strategies for overweight and obesity, the different
levels of preventive action, and the need to deal with individuals with
existing obesity. It highlights the need for coordinated action in a
variety of settings and shared responsibility on the part of key stakeholders. It is emphasized that:
Coherent and comprehensive strategies for the effective prevention and management of obesity should focus on:
154
Until recently, obesity prevention and obesity management were perceived as two distinct processes, the former being aimed at preventing
weight gain and the latter concerned with weight loss. Management
was seen as the role of the clinician, whereas prevention was considered to be the domain of health promotion or public health departments. However, it is now realized that obesity management covers a
whole range of long-term strategies ranging from prevention, through
weight maintenance and the management of obesity comorbidities, to
weight loss (1; see Fig. 8.1). The individual strategies are interdependent, so that truly effective obesity management must address all of
them in a coordinated manner and in a variety of settings.
Strategies to deal with the immediate and existing health problems of
those who are already obese often take precedence in discussions on
obesity management. However, as Fig. 8.1 shows, considerably more
attention needs to be given to prevention activities than is the case at
present, as these are likely to have a much greater impact on the
effective long-term control of obesity.
8.3
Prevention strategies
Figure 8.1
Obesity management
Promotion of weight
maintenance
__
Management of obesity
comorbidities
WH098269
The diagram shows the broad range of overlapping activities that are an integral part of
obesity management. The size of each element indicates its relative contribution to the
effective control of obesity.
a
Adapted from reference 1 with the permission of the publisher Churchill Livingstone.
Effectiveness
Finally, a number of researchers (18-21) have shown that the effective management and support of overweight and obese children can
significantly reduce the number who continue to have a weight problem in adulthood. The long-term prevention of weight gain in these
studies was achieved during the difficult transition periods of childhood and adolescence when weight gain can be a major problem.
Furthermore, in a study in which children were treated together with
their parents, the children were successful in reducing and maintaining their weight loss while over time the adults returned to their
previous body weight (21).
8.3.2 Aims
158
Figure 8.2
Mean BMI by educational level in men and women from 1972 to 1992 in the
North Karelia and Kuopio areas of Finland
28
28
MEN
WOMEN
Medium
Low
27
27
"'
-- '
26
'
''
'
'
''
'
' ''
''
' '
'
"'
High
'
26
Medium
''
''
''
''
''
25
25
1972
1977
1982
1987
1992
Year
1972
1977
'
''
''
''
''
''
,-- __ .- High
"'
1982
Year
1987
1992
WHO 98283
The data show that the mean BMI of Finnish men from low- and high-education groups has
actually declined from a peak in 1987. In Finnish women, the mean BMI declined until 1982
but increased afterwards. Although it appears to be levelling off in women from high- and
medium-education groups, it continues to increase rapidly in low-education groups. These
data suggest that it may be possible to prevent further increases in the average weight of the
Finnish population if the success achieved with the better-educated groups can be extended
to the rest of the population.
a
Adapted from reference 17 with the permission of the publisher and authors.
Figure 8.3
WHO 98270
The diagram shows the three different, but complementary, levels of preventive action for
dealing with weight gain and obesity. The very specific targeted-prevention approach is
represented by the central circle, the selective preventive approach directed at high-risk
individuals and groups is represented by the middle ring, and the broader universal or
populationwide prevention approach is represented by the outer ring.
a
Adapted from reference 1 with the permission of the publisher Churchill Livingstone.
and the prevalence of obesity is discussed in section 9. Other objectives of universal prevention include a reduction in weight-related illhealth, improvements in general diet and PALs, and a reduction in
the level of the population risk of obesity.
Such a mass approach to the control and prevention of lifestyle diseases is not always appropriate, and has been criticized for requiring
everyone, whether at high or low risk, to make the same changes (23).
In the prevention of overweight and obesity, however, where the
prevalence of the condition is already extremely high and a large
proportion of the population is at high risk, universal approaches
have the potential to be the most cost-effective form of prevention
(24).
Selective prevention
Selective prevention measures are aimed at subgroups of the population who are at high risk of developing obesity. High-risk subgroups
(identified in section 7) are characterized by genetic, biological or
161
Targeted prevention is aimed at individuals who are already overweight and those who are not yet obese but in whom biological
markers associated with excessive fat stores have been identified.
These are high-risk individuals, and failure to intervene at this stage
will result in many of them becoming obese and suffering the resulting
ill-health in the future.
The primary objectives of the targeted prevention of obesity are
limited to the prevention of further weight gain and to the reduction
of the number of people who develop obesity-related comorbidities.
Patients recruited to targeted prevention programmes will already
have some weight-related problems and require intensive individual
or small-group preventive intervention. Individuals at high risk of
developing obesity comorbidities such as CVD, NIDDM and arthritis
are a key target for this prevention strategy. Preventing overweight
children from becoming obese adults is a form of targeted prevention.
8.3.4 Integrating obesity prevention into efforts to prevent other
noncommunicable diseases
(Integrated Programme for the Prevention and Control of Noncommunicable Diseases), the CINDI programme (Community Interventions in Noncommunicable Diseases) and the MONICA project for
CVD risk-factor monitoring have been important examples of an
integrated (horizontal) approach to the NCD epidemic. They are all
based on the recognition that all NCDs have a number of common
risk factors, necessitating an integrated approach to their prevention,
particularly in view of the problem of funding priorities resulting
from the emergence of devastating communicable diseases, such
as AIDS and Ebola virus disease, and the re-emergence of
tuberculosis.
In developed countries, overweight and obesity are seen predominantly in the socioeconomically disadvantaged segments of the population. Public health measures to control NCDs are still inadequate
and equity considerations make the introduction of such measures a
high priority. The prevention of obesity, in parallel with existing
efforts to control other risk factors for NCDs, should provide better
control of these diseases. However, such strategies should focus more
on obesity per se rather than treating it as just another risk factor for
NCDs.
In developing countries, where nutritional deficiency disorders and
the emerging epidemic of NCDs require attention at the same time,
integrated activities designed to meet multiple demands are likely to
be of greatest benefit. The prevention of NCDs, including overweight
and obesity, should be a public health priority since limited resources
will quickly be exhausted by the demand for expensive and technologically advanced curative care, especially in countries in transition.
Furthermore, the expected reversal of the social gradient associated
with the NCD epidemic will pose insurmountable problems of equity
and access to health in these countries.
8.4
Given the high prevalence rates of obesity and the well developed
national health care systems in many countries, it would seem reasonable to assume that well coordinated and systematic management
services exist to deal with obesity. However, the current situation is
far removed from this ideal.
In a preliminary survey, Deslypere examined obesity-management
approaches in existing national health care services in Australia and
in a number of countries in South America, South-East Asia and
Europe. 1 A wide variation in obesity care services was found; very few
countries had a coherent and comprehensive range of services capable of providing the level of care required to manage obese patients
effectively. This is in stark contrast to the situation with regard to
other chronic diseases such as NIDDM and CHD, where integrated
care is frequently provided through primary health care services.
The Czech Republic, where a five-year plan for the prevention and
management of obesity has been established, provides a welcome
exception to the rule (V. Hainer, personal communication). A wide
range of therapies including diet, exercise, behaviour modification,
drug therapy and surgery are currently employed for the treatment of
obese patients. Mild-to-moderate obesity is dealt with through
weight-reduction clubs, while moderate obesity with comorbidities
is treated in obesity outpatient clinics. Severely obese patients are
referred to specialist university obesity clinics. Internists receive
postregistration training in the care of obese patients, and an obesitymanagement handbook has been prepared for nurses and another is
being prepared for family doctors. Obesity specialists are also involved in the training of counsellors for weight-loss clubs.
8.4.2 Knowledge and attitudes of health professionals
Several studies have shown that family doctors and other primary
health care professionals have incomplete, confused and occasionally incorrect knowledge of obesity and nutrition (25-27). Often
the basic facts about weight control are understood, but confusion abounds in relation to how best to manage and advise patients
or the public (28). Certain genetic and metabolic disorders that
lead to the development of obesity are often given undue prominence in discussions in medical textbooks about weight gain and
164
Deslypere JP, ed. The primary health care-specialist interface, 1996. Background paper
prepared by Primary Health Care-Specialist Interface subgroup of the International
Obesity Task Force.
49, 50). Thus, preventing weight gain and obesity is likely to be more
effective in the long term than treating its consequences once it has
developed.
8.5
The concept of shared responsibility for the prevention and management of obesity is illustrated in Fig. 8.4, which shows how strategies to
promote an appropriate diet and physical activity involve coordinated
action by all the sectors concerned.
Promoting healthy diets
The promotion of healthy diets that are low in fat, high in complex
carbohydrates and contain large amounts of fresh fruit and vegetables
should be a priority in obesity prevention. Although it is consumers
who ultimately choose which foods to consume, their choices are
influenced by a number of factors such as experience, custom, availability and cost. These factors, in turn, are affected by the actions of
government, the food industry and the media. Food availability, for
example, depends on the capacity of industry to produce and deliver
products to the consumer at affordable prices, and to promote them
appropriately, as well as on government policy on food standards, and
on subsidies and taxes on food products.
Consumption of a high-fat diet may reflect government policies on the
control of food quality, the advertising of high-fat products by the
food industry and the media, ready access to processed high-fat fast
foods, lifestyles that favour the convenience of preprepared meals,
and excessive consumption driven by the pleasant mouth-feel of fat
when eaten.
The shared responsibilities of governments, the food industry, the
media and consumers, outlined above, offer multiple sites for intervention. Appropriate targets for nutrition strategies identified by
FAO and WHO (51-53) include consumer education and protection,
167
Figure 8.4
a shared responsibility
Healthy weight
for all
A shared responsibility
Government
Consumer
Industry/trade
Media
Educated and
knowledgeable
public
Trained markete~
and manage~
Responsible
advertising
Advice for
industry/trade
Discriminating
and selective
consume~
Appropriate
availability and
promotion
Health
communication
and education
Consumer
education and
protection
Healthy practices
in the home
Quality
assurance
Advocacy
Information
gathering and
research
Community
participation
(attitudes and
practice)
Informative
labelling and
consumer
education
Publicizing
successes
Provision of
health-related
services
Active consumer
groups
Exposing
fraudulent
health claims
168
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172
173
9.
9.1
Introduction
Figure 9.1
Relationship between mean BMI and prevalence of obesity in a population
The relation between population mean and the prevalence of deviant (high) BMI values
across 52 population samples from 32 countries (men and women aged 20-59 years)
60
r=0.94
b = 4.66% per unit BMI
50
.~ 40
"'<11
.0
.....00
~
e...
30
-,.
<11
u
<11
"iii
20
>
'~
c...
.il'
....:,
10
0
15
20
25
30
MeanBMI
35
WH098282
Population mean body weight data from 52 communities in the International Cooperative Study
on the Relation of Blood Pressure to Electrolyte Excretion in Populations (INTERSALT) are
plotted against the prevalence (%) of obesity; the curve shows the clear relationship between
them.
a
Adapted from reference 3. This figure was first published in: lntersalt: an international study of
electrolyte excretion and blood pressure. Results for 24 hour urinary sodium and potassium
excretion. British Medical Journal, 1988, 297:319-328. Reproduced with the permission of the
British Medical Journal.
of obesity
The classification of obesity as a BMI ~30 (section 2) is purely arbitrary. It indicates that health risks are greatly increased above this
level of body fatness but not that BMis below this level are free from
such risks. In reality, the population does not consist of two distinct
176
Figure 9.2
BMI
WH098281
The data from the INTERSALT study show that, as the mean population BMI increases, the
level of obesity increases at an even faster rate because of the skewing of the distribution to
higher BM Is. Public health interventions seek to prevent this upward shift in mean population
BM I.
a
Adapted from reference 3. This figure was first published in: lntersalt: an international study of
electrolyte excretion and blood pressure. Result for 24 hour urinary sodium and potassium
excretion. British Medical Journal, 1988, 297:319-328. Reproduced with the permission of the
British Medical Journal.
groups, the obese and the non-obese. The distribution of body fatness
within a population ranges from underweight through normal to very
obese, and the risks of associated morbidity and mortality begin at
relatively low levels of BMI.
The analysis by Rose (3) of the multicountry International Cooperative Study on the Relation of Blood Pressure to Electrolyte Excretion
in Populations (INTERSALT) provides a useful evaluation of body
weight data from 52 communities. In this study, variations in the
distribution of BMI in different adult populations were found that
could be predicted from the population mean BMI. When the mean
BMI of a population is 23 or below there are few, if any, individuals
with a BMI >30. As the BMI distribution of the community shifts to
the right (i.e. as mean BMI increases), there is an increased skewing of
the data and a flattening of the curve (Fig. 9.2). The result is a greater
number of individuals in the population whose BMI exceeds 30.
177
Perhaps of greatest significance, however, is the accompanying increase in the proportion of adults classified as obese, which takes
place at an even faster rate than the increase in average BMI. Rose
found a 4.66% increase in the prevalence of obesity for every single
unit increase in the population's average BMI above 23, resulting in a
strong correlation between the average adult BMI of a population
and the proportion of adults with obesity (Fig. 9.1). In the United
Kingdom between 1980 and 1993, the mean BMI increased from 24.3
to 25.9 for men and from 23.9 to 25.7 for women. Over this same
period, the rates of overweight increased by one-third, whereas those
of obesity doubled. This implies that further increases in mean BMI
are likely to result in even more dramatic rises in the rates of obesity.
It is believed that, for the effective prevention of obesity, the empha-
The optimum mean BMI for a population is likely to vary with environmental conditions, e.g. the state of the labour market and the
possibility of famine, which differ between developing and developed
countries, as well as between urban and rural areas. For example,
there are substantial differences in the nutritional status and mean
BMI of urban and rural Chinese and Indian communities that reflect
vastly different economic and environmental circumstances.
Hazards are associated with both underweight (i.e. BMI <18.5) and
overweight (i.e. BMI 2':25). Underweight is a major concern in developing countries and rural areas because work capacity is reduced at
BMis below 18.5 (4). Thus, epidemiological studies of national data
sets suggest that developing an optimum population BMI will require
a trade-off between the two extremes. If the aim is to minimize both
the number of adults in a community with a BMI 2':30 (Fig. 9.2) and
that of underweight adults with a BMI <18.5, the optimum BMI is
about 23. Indeed, the probability of an increasing prevalence of obesity rises markedly above a mean BMI of 23. However, if the aim is to
limit the extent of overweight by minimizing the proportion of the
population with a BMI 2':25, and there is less concern about limiting
the number of adults with a BMI <18.5, a median BMI of 21 is the
optimum (5).
In industrialized countries there is evidence that a BMI in the lower
part of the normal range is associated with the best health outcomes
178
They have generally relied on the mass media, workplace interventions, school-based programmes and curricula, skills training in a
network of clubs and community centres, and community projects to
reach a wide audience so as to provide information and promote
behaviour change.
While strategies aimed at improving the knowledge and skills of the
community have produced impressive results in dealing with many
public health problems, this is not true, however, of obesity. This may
be because manipulating the diet to prevent public health problems
does not induce the same fundamental adaptive responses in eating
that are seen when children and adults are underfed in terms of
energy. Communities are already generally well aware of the problems associated with obesity, and many individuals are actively attempting to control their weight. Participation rates in this type of
obesity control programme are usually high, and many succeed in
reducing their weight in the short term. Nevertheless, there is generally little impact on the overall average BMI of the community and a
negligible effect on obesity prevalence, so that preventive strategies
are obviously of great importance.
9.3.2 Reducing population exposure to an obesity-promoting
environment
A more effective strategy for dealing with the public health problem
of obesity would appear to be one that goes beyond education and
deals with those environmental and societal factors that induce the
obesity-promoting behaviour of individuals within a population in the
first place (see Fig. 7.1). In this way, it may be possible to reduce
the exposure of the whole population to social factors that promote
obesity, such as the persistent temptation to consume high-fat foods
and the convenience of a sedentary lifestyle. Unfortunately, however,
such strategies remain relatively unexplored.
9.4
Priority interventions
Care is therefore needed when both the energy density and the nutrient/energy ratio of diets are examined. The age group targeted in
health promotion strategies as well as the normal dietary constituents
available to them should be taken into account. When diets are based
essentially on unrefined indigenous local foods, and contain a suitable
proportion of cereals, pulses, vegetables and affordable animal proteins, there is less likelihood that either their energy density or their
nutrient/energy ratios will be inappropriate. Identifying the optimum
ranges of both nutrient/energy ratios and energy densities for young
children and the corresponding ratios and densities for older children
and adults is still difficult.
For information on the national nutrition programmes of Finland and
Norway, see pp 188-189.
9.4.3 Measures for use in evaluating obesity-prevention programmes
To date, there have not been any well evaluated and properly organized public health programmes aimed at the population-level management or prevention of obesity. A number of countries have
recently developed lifestyle strategies in which the emphasis is on
weight control but, except in Singapore, these have not taken the
form of controlled trials and so are unlikely to provide any definitive evidence of their impact. The best examples of such trials are
community-wide CHD prevention programmes that have included a
reduction in BMI as one of the measurable outcomes.
183
Alternatively, some programmes have targeted those factors identified as important in the development of obesity, namely physical
activity and the quality ofthe diet. However, it is debatable how much
can be deduced from the results of such programmes as far as the
potential of public health strategies to manage weight is concerned.
9.5.1 Countrywide public health programmes
Over the last 20 years a handful of well funded, large-scale, communitywide intervention programmes intended to prevent CHD have
184
in CHD risk factors, which were still declining in 1992 (22), the
average BMI and the level of obesity remained similar throughout
the project, and similar trends have been observed since its conclusion (23).
The following possible reasons for communitywide CHD intervention programmes being disappointing in terms of obesity and weight
control have been suggested by Jeffery (20):
The main emphasis of the programmes was on CHD risk and not
obesity. Weight reduction was generally viewed as a method of
facilitating risk factor reduction rather than as an outcome in its
own right.
Rapidly rising secular trends in weight may have overwhelmed any
effects of interventions aimed at curbing the rise.
Powerful societal and environmental obesity-promoting factors
have developed rapidly in many societies over the last few decades,
and the intervention programmes may not have been strong
enough or sufficiently well coordinated to overcome them.
The interventions may not have reached a sufficiently large proportion of the community to have an impact on the weight status of the
population as a whole. In many communities, a large percentage
are already concerned about weight and are trying to control it, so
that even intensive interventions may not increase the number of
people actively participating in weight-control programmes.
The interventions may have been aimed at making too many
changes at once (e.g. reducing cholesterol levels, controlling blood
186
of obesity
Countrywide programmes aimed at increasing physical activity
Although the improvements achieved by communitywide programmes for increasing physical activity tended to be only short-lived, they
do suggest that participation in physical activity can be increased by
such programmes. Some of the limitations of communitywide CHD
prevention programmes discussed earlier are equally applicable to
programmes intended to increase physical activity. With very few
exceptions, most of the intervention strategies were aimed at improving the awareness of, and motivation to, exercise without tackling the
environmental obstacles to increased participation. The Minnesota
Heart Program did attempt to improve exercise facilities in the community and to involve community groups in establishing their own
committees to review other methods of increasing activity, but most
other programmes relied on interventions based on personal education and behaviour change. In all the programmes, the interventions
were aimed at improving the levels of leisure-time exercise, and did
not attempt to influence factors such as transportation and urban
design that have an impact on occupational and leisure-time daily
activity patterns.
The feasibility of long-term maintenance of increased physical activity and its benefits for obesity prevention remain to be demonstrated
(27, 29).
National nutrition programmes
The energy density and fat content of the food supply have been
identified as the major dietary factors implicated in the development of
obesity (section 7). In many countries, national nutrition programmes
have succeeded in dramatically altering the fatty-acid composition of
diets, and some have also been successful in achieving a small reduction in the intake of total fats. However, very few countries have been
able to reduce total fat intake to the level that would appear to be
necessary to influence the average BMI of the whole population. This
is not surprising, as very few countries have a comprehensive and
integrated national nutrition policy that can direct the actions at all
levels necessary to achieve such a dramatic dietary change.
Two countries that have instituted far-reaching national nutrition
programmes are Finland and Norway. These countries have been able
to reduce national fat intake from 42% to around 34% of total dietary
energy over the last 20 years. It is therefore encouraging to see that
the increase in obesity prevalence is slowing in Finland and that the
mean BMI is stabilizing or even falling in some areas despite simultaneous decreases in levels of physical activity (23) {Fig. 9.3). In Norway, data for all 40-42-year-old men and women recruited to a
countrywide CHD prevention programme (except Oslo) were
188
Figure 9.3
Changes in mean BMI in men and women in four areas of Finland between 1972
and 1992"
WOMEN
MEN
28
28
27
27
........... .......;......
~~:::.:-".:..
26
26
,,
25
25
24
24
1972
1977
1982
1987
1992
1972
N. KARELIA
1977
1982
1987
1992
Year
Year
KUOPIO PROVINCE
S.W. FINLAND
HELSINKI AREA
WH098280
The curves show that mean BMI for men in North Karelia and Kuopio has stabilized or even
fallen since 1987 after rapid rises in the preceding 15 years. The rise in mean BMI for women
in the same provinces observed after 1982 also appears to be levelling out. This suggests that
the communitywide changes in diet that have occurred in these provinces over the past 25
years may be contributing to a stabilization of population mean BMI.
Adapted from reference 23 with the permission of the publisher and authors.
analysed in a recent study and it was found that obesity rates had
decreased slightly in women since the 1960s (30). In Norwegian men,
obesity rates remain lower than in other European countries but, in
contrast to the Norwegian women, have increased substantially since
the 1960s.
9.5.4 Implications for future public health programmes to control obesity
Table 9.1
Main features of successful public health campaigns
Feature of campaign
Example
Adequate duration
and persistency
Legislative action
Education
Advocacy
Shared
responsibility by
consumers,
communities, food
industry and
governments
Table 9.2
Possible environmental strategies for obesity control"
Area for action
School curricula
Promotion and
education
193
Table 9.2
(Continued)
Area for action
Adapted from reference 32 with the permission of the publisher Churchill Livingstone.
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2. Atrens OM. The questionable wisdom of a low-fat diet and cholesterol
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196
10.
10.1 Introduction
Targeted prevention -directed at those with existing weight problems and those at high risk of diseases associated with overweight.
Weight-management programmes can therefore be initiated to target
those high-risk individuals and subgroups of the population identified
in section 7.
As pointed out in section 8, there is an urgent need for intervention
studies specifically aimed at preventing weight gain in adults. So far,
the results of only two such studies have been reported. The first was
a small-scale trial in a relatively select group 1 of normal-weight individuals to determine whether a low-impact intervention involving
an educational programme (four nutrition education sessions and
a monthly weight-control information newsletter) and a financial
incentive could reduce weight gain. After 1 year, those in the treated
group had lost about 1 kg in weight, while the weights of those in the
control group remained unchanged (1). Analysis of the results
showed that the greatest impact was among men, individuals over the
age of 50, non-smokers and those with little prior experience of formal weight-loss services. The second report describes the first-year
results of the Pound of Prevention (POP) study, an ongoing continuation of the first study that adopts a similar approach but applies it to
a larger population (more than 1000 participants) over a longer period (2). Among men and high-income women, early trends in combating weight gain were encouraging and, if sustained over 3 years,
should produce a positive outcome. However, trends in the lowincome group were negative at 1 year. Further follow-up will reveal
whether the low-intensity educational strategy being tested is effective in reducing the rate of weight gain in the groups being studied,
and the study may help to identify behavioural correlates of weight
gain that could provide guidance for further research on this important topic.
Prevention at the workplace
199
USA, a 2-year study of cigarette smoking and obesity found no differences in the mean BMI or any change in BMI at workplaces that
offered weight-loss classes (on four occasions) compared with those
that did not (4).
Prevention through health care services
The management of obesity comorbidities can improve health outcomes regardless of whether or not substantial weight loss is achieved
(9, 10). As highlighted in section 4, such comorbidities range from
chronic debilitating, though not life-threatening, conditions to severe
health risks associated with hyperlipidaemia and hypertension. Appropriate targets relating to the management of obesity comorbidities
are suggested in Table 10.1.
200
Figure 10.1
Possible indicators of success in obesity-management programmes"
Body weight
. ~tgain
................................
r\lllel9
...........
seo~W~~,:.......................
)c.oU
~atufa
...................
Obese
Successes
Overweight
Normal
'------------ .....
Treatment strategies
WHO 98279
Weight maintenance or minor weight loss are successful outcomes of programmes aimed at
controlling obesity when otherwise (without intervention) weight gain would occur.
a
Adapted from reference 8 with the permission of the publisher and author.
Table 10.1
Appropriate targets for the management of obesity and comorbidities
Condition
Appropriate targeta
Fatness
Abdominal fat
Hypertension
Dyslipidaemia
Sleep apnoea
Reproductive
dysfunction
Poor psychosocial
functioning
Tiredness, sweating,
breathlessness etc.
Exercise intolerance
Quantitative estimates of magnitude of change in target value may vary for specific
populations.
Clinical trials show that most patients are unable to continue losing
weight for longer than 12-16 weeks (4-Skg loss) and that weight
loss does not continue after 6 months (14). Patients are seldom
applauded or rewarded for achieving this modest loss, even though
it requires prolonged hard work and brings major health benefits.
10.3
Recruiting at-risk groups and individuals is the first step in an effective weight-management protocol. The three main methods of recruitment and referral are as follows:
welfare clinics, and screening programmes for tuberculosis, infestations and cancer of breast and cervix.
10.3.2Comprehensive health assessment
The development of an effective weight-management strategy depends on a comprehensive analysis of the individual's degree of
obesity, his or her associated risks, coexisting illnesses, social and
personal situation, and a history of those problems and precipitating
factors that led to weight gain. The components of such an analysis
might include those outlined below.
Personal weight history
Where resources are available, the health assessment might include the analysis of blood and urine for metabolites indicative of
disease risk, e.g. plasma glucose and blood lipids. Some tests carried
out routinely in overweight and obese patients (e.g. hormone levels
for rare abnormalities) are considered to be an unwise use of
resources.
10.3.3Setting appropriate targets
206
Deslypere JP, ed. The management of obesity through health care services, 1996.
Background paper prepared by Primary Health Care-Specialist Interface subgroup of
the International Obesity Task Force.
Figure 10.2
A systematic approach to obesity management based on BMI and other
risk factors
Assess overall health risk from BMI and other risk factors, e.g. waist circumference
INo I
BMI
18.5-24.9
Management strategies
IYes I
Average:----------+
Increased
BMI
25-29.9
BMI
30-34.9
BMI
35-39.9
Severe
Very severe~
BMI
~40
Very severe
WHO 98272
207
a personal support scheme that includes specially trained personnel and, if possible and appropriate, family involvement;
dietary assessment followed by individually tailored advice;
analysis and modification of physical activity patterns;
behavioural advice that links environmental and psychosocial factors to the changes needed in diet and physical activity;
additional treatments may also be indicated depending on the
degree of overweight and the presence of comorbidities.
Table 10.2
Potential criteria for evaluating weight-maintenance strategy
Maintenance of a stable weight over time (even if BMI is not reduced to within the
normal range)
Reduction in the number of obese people who develop obesity-related
comorbidities
Increase in the number of obese people who are successful in attaining and
maintaining modest weight losses
Reduction in the number of individuals who gain even a small amount of weight
over a specified period
Low withdrawal rates
Low relapse rates
Improvement in risk factors and comorbidities
A number of studies have shown that the body weight and attitudes of
a patient's spouse can have a major impact on the amount of weight
lost and on success in weight maintenance. Black & Threlfall (29)
found that overweight patients with normal-weight partners lost significantly more weight than those with overweight partners. They also
noted that success was greater in those patients whose partners had
also lost weight (even though they were not included in the
programme), suggesting that recommended changes were being actively supported by the spouse. Similarly, Pratt found that drop-out
rates were reduced when the patient's spouse was included in a
weight-control programme (30).
209
Additional evidence for the important role of family support in successful weight management is provided by the work of Epstein and
colleagues (31) on the treatment of childhood obesity.
10.4.3Self-hetp and support groups
In recent years there has been a large increase in the number of selfhelp and support groups. These range from national organizations
such as Overeaters Anonymous (OA) in the USA and Anonymous
Fighters Against Obesity (ALCO) in Argentina, Chile, Paraguay,
Spain and Uruguay, to smaller workplace, neighbourhood and
community-organized self-help groups. These groups generally consist of people with weight or eating problems, and operate at little or
no cost and without professional intervention. They all offer considerable social support but vary in their philosophy. Unfortunately, although such groups are immensely popular, there has been no
objective assessment of their value in weight management. However,
well run self-help groups are a useful and inexpensive form of continuing group support; they encourage long-term participation and
can be a useful adjunct to professional care.
Advocacy groups for overweight and obese persons, such as the Size
Acceptance Network in the USA, serve a different function from selfhelp groups, aiming to reduce the stigma and social difficulties that
obese patients suffer. Recently, a patient support and advocacy group
called EUROBESITAS has been established to lobby for the rights of
obese patients in Europe.
10.4.4 Commercial weight-toss organizations
effectiveness of commercial programmes have resulted in few objective assessments because of problems of confidentiality, drop-out
rates and lack of interest among the organizations themselves (32).
The US Food and Nutrition Board Committee has suggested that
there is a need for guidelines on voluntary accreditation within the
commercial weight-loss industry (15). The misleading marketing of
weight-loss programmes has often been a cause of complaints to
consumer organizations.
Nevertheless, many well run programmes provide the support and
interest needed for long-term involvement in weight management
that cannot be provided by health professionals. Commercial weightloss organizations should therefore be required to comply with a code
of practice in relation to fees, training of counsellors and promotion of
their services. They should also report the outcomes of their
programmes. Health professionals may consider the judicious use of
such organizations in obesity management after assessing their merit,
using the criteria suggested by the Scottish Intercollegiate Guidelines
Network (Annex 1).
1o.s
Treatment of obesity
This dietary scheme is based on inducing an energy deficit that patients can sustain over the long term. A deficit of 500-600kcal1h/day
(2092-2510kJ/day) is usually well tolerated. When used correctly, this
approach has resulted in larger weight losses over time than attempting more severe energy restriction (34).
The specific energy intake prescribed to patients is based on an estimate of their initial maintenance requirement minus the agreed deficit. Maintenance estimates should be calculated from the equations of
Lean & James (35), based on body weight and age, rather than from
self-reported dietary intakes since these are notoriously unreliable
when obtained from obese subjects (36). After subtracting the deficit,
the energy prescription can be translated into a dietary plan using a
food exchange table based on healthy eating principles, i.e. approximately 20-30% or less energy as fat, 15% as protein, and 55-60% or
more as carbohydrate (primarily complex carbohydrates). The assessment of current dietary patterns should be used to construct and
educate the patient to follow a dietary plan appropriate to his or her
circumstances. The prescribed energy level of such plans should generally not be lower than 1200kcal1h/day (5021kJ/day).
Low-fat, high-carbohydrate diets
The standard practice in many lay and commercial systems for slimming is for the patient to be prescribed a standard energy intake,
normally 1000-1200kcal1h/day (4184-5021kJ/day). These intakes are
usually selected by dietitians or doctors in accordance with nutritional
212
Table 10.3
Suggested mechanisms linking exercise with the success of weight
maintenance
Increased energy expenditure
Better aerobic fitness
Improved body composition:
fat loss
preservation of lean body mass
reduction of visceral fat depot
Increased capacity for fat mobilization and oxidation
Control of food intake:
short-term reduction of appetite
reduction of fat intake
Stimulation of thermogenic response:
resting metabolic rate
diet-induced thermogenesis
Change in muscle morphology and biochemical capacity
Increased insulin sensitivity
Improved plasma lipid and lipoprotein profile
Reduced blood pressure
Positive psychological effects
a
Reproduced from reference 50 with the permission of the publisher. Copyright John Wiley &
Sons Ltd.
least once a week are less likely to have NIDDM or CVD, hip fractures and mental illness, and have lower mortality rates than those
who are least active. Integrated exercise schemes consistently show
the beneficial effects of physical activity and exercise on both physiological and psychological well-being (48, 49).
Table 10.3 summarizes the possible mechanisms whereby exercise can
improve the success of weight maintenance.
Achieving appropriate levels of physical activity
Evidence now suggests that the activity required to maintain and lose
weight, and to gain physiological and psychological health benefits,
may not have to be as vigorous as was previously believed (48, 51).
Indeed, the US Surgeon General's report (48) stressed that lowintensity, prolonged physical activity, such as purposeful walking for
30-60 minutes almost every day, can substantially increase energy
expenditure, thus reducing body weight and fat.
Physical activity strategies should aim at encouraging higher levels of
low-intensity activity and reducing the amount of leisure time spent in
sedentary pursuits. The main goal is to convert inactive children and
adults to a pattern of "active living". Two general schemes can be
envisaged for promoting physical activity:
214
Analysis of randomized trials of public involvement in physical activity programmes (53) has indicated that compliance is improved by:
-
Method of treatment
Drugs for weight management do not work if they are not taken
(59). Weight regain can be expected when drugs are discontinued.
Drug treatment should be considered part of a long-term management strategy for obesity tailored to the individual. Risks associated with drug treatment should be balanced against those of
persistent obesity.
Drug treatment should be continued only if it is considered to be
safe and effective for a given patient. Current criteria in the United
Kingdom suggest that the use of weight-management drugs for
longer than 3 months should be considered only if a total weight
loss of at least 10% has been achieved from the start of the episode
of managed care (i.e. including weight loss achieved as a result of
the obligatory 3-6 months of lifestyle intervention before drug
treatment is initiated (60). However, this principle has been criticized as being unrealistic in most cases.
Drug treatment for obesity can be considered when patients:
-
have a BMI >30 and treatment with diet, exercise and behaviour
regimens has proved unsuccessful;
have substantial comorbidities associated with a BMI >25 that
have persisted in spite of an improved diet, exercise and
behavioural treatment.
Weight-management drugs can be broadly divided into two typesthose that act on the central nervous system to influence feeding
behaviour, appetite and other mechanisms, and peripherally acting
drugs such as those that target the gastrointestinal system and inhibit
absorption or enhance a feeling of fullness. As there is no published
evidence to suggest that bulk-forming agents taken in a medicated
form (e.g. methylcellulose) have any beneficial long-term effect in
reducing weight, they are not discussed further here. However, increasing dietary fibre as part of dietary modification may have a role
in energy restriction.
Weight-management drugs currently available in certain countries
are summarized in Table 10.4. A number of them are considered in
greater detail below. Many additional agents are currently under
investigation.
In 1997 concerns were raised about the safety of two widely used
weight-management drugs, fenfluramine and dexfenfluramine, be218
Table 10.4
Anti-obesity drugs currently available for use
Principal mode of action
Centrally acting:
noradrenergic
combined serotonergic and noradrenergic
Peripherally acting:
lipase inhibitor
Peripherally and centrally acting
thermogenic and anorectic
Drug
Phentermine
Sibutramine
Tetrahyd rol ipostatin
Ephedrine; caffeine
cause of their association with heart valve problems when used alone
or in combination with phentermine. As a result of these concerns the
manufacturer agreed to withdraw both treatments from the market.
These drugs are therefore not considered in this report.
Efficacy of currently available drugs
A clinically useful drug for obesity treatment should have the following characteristics (61):
Tetrahydrolipostatin is a pancreatic lipase inhibitor developed specifically for weight management. It blocks the cleavage of triglycerides in the gastrointestinal tract and thereby prevents
Tetrahydrolipstatin.
Details of safe and efficacious dosages are beyond the scope of this report; appropriate
medical references should be consulted. Drug approval agencies such as the Food and
Drug Administration in the USA require drugs to produce at least 5% greater weight loss
than a placebo, or to result in significantly more subjects achieving a 5-10% weight loss
than can achieve a s'1milar loss with a placebo.
219
220
Concerns about the possible side-effects (heart valve problems) associated with the use
of fenfluramine and dexfenfluramine, either alone or in combination with phentermine,
led to the withdrawal of these drugs from the market.
Patients should be selected for surgery in accordance with the following principles:
Non-surgical treatment including dietary measures and weightreducing drugs should be tried first.
Gastrointestinal surgery for obesity should be used only on well
informed and motivated patients with acceptable operative risks.
Patients should have a BMI >40, or >35 together with high-risk, lifethreatening comorbid conditions.
Surgery should be undertaken only by an experienced surgeon
in an appropriate clinical setting under expert medical surveillance, and with access to ventilator facilities and the support of a
multidisciplinary team.
Improvements after surgery
Risks associated with gastric surgery include micronutrient deficiencies, neuropathy, postoperative complications, "dumping syndrome"
and late postoperative depression (74). It has been suggested,
however, that most of the complications associated with this type of
surgery, unlike most other surgery, are treatable with behavioural
therapy. Kral (77), for example, notes that the vomiting seen in
approximately 10% of patients after surgery is due more to eating
behaviour than to stenosis or stricture of the gastroplasty stoma.
Operative mortality in experienced centres is a fraction of the mortality observed in unoperated patients and in those remaining on waiting
lists for operations. 1
Liposuction of unwanted subcutaneous fat depots is being used extensively for cosmetic reasons but offers no medical benefit in terms of
comorbidities linked to obesity.
10.5.6 Traditional medicine
Many countries have traditional medical systems that provide treatment in addition to, or in place of, conventional medical services.
Traditional treatments for a range of illnesses, including obesity, are
often available and are commonly used by people in developing countries. Although there are limited data on the efficacy of the medicines
used, there is anecdotal evidence of their potential value. For example, some preparations of plant products containing capsaicin have
been shown to increase energy expenditure by increasing thermogenesis (78). More research is required to evaluate the potential use of
such traditional remedies.
Caution is necessary, however. A variety of herbal preparations
widely promoted by commercial organizations as traditional remedies
have been shown to be of little medical value and, in some cases, to
contain dangerous substances.
10.5. 7 Other treatments
Kral JG. Surgery. In: Guy-Grand B, ed. Management of obesity and overweight, 1996.
Background paper prepared by Obesity Management subgroup of International Obesity
Task Force.
223
adult obesity
Figure 10.3
Changes in percentage overweight after 5 and 10 years of follow-up for obese
children randomly assigned to 10 interventions across four studies
A. 25~======~----------~
20
B. 25~==========~--------~
Non-specific
15
20
15
-, 10
-~
----
Non-obese parents
Obese parents
?f. 0
-~
-5
c:n
c
J!!-10
u
-15
-20
-25
-12
-25 L__L__L_j___l_L_.l__L_j___t_L__L_..J
-12 0 12 24 36 48 60 72 84 96 108 120 132
Months
c.
D.
25
Diet
20
-, 10
'Qj
~ 5
~
0
-~
Q)
c:n
Diet+
Lifestyle
-----
15
Months
20
15
~ 5
-~
Q)
c:n
0
-5
c
J!!-10
c
6-10
-15
-15
-20
-20
-25
-12
Months
'Qj
'#.
-5
Calisthenics only
-,10
25 r-;::========::::;---------~
Months
WH098278
The 95% confidence interval for the total sample of children is represented by dotted lines.
The interventions all contained a diet and behavioural change component plus the specific
approaches under investigation. In the four separate studies in which Epstein et al. examined
the impact of different interventions for obesity management in overweight children, all had the
same basic diet and behavioural change intervention for 8-12 weeks and monthly review for
6-12 months. Study A compared results for children alone, children with one parent, and
nonspecific directions. Study B compared relative weight changes in children of obese and
non-obese parents. Study C examined the benefit of adding lifestyle (unstructured exercise) to
a diet programme. Study D compared the effectiveness of different forms of exercise in aiding
weight control. Both children and parents were followed up 5 and 10 years after the initial
programme. The results show excellent long-term benefits and demonstrate the value of family
support and a positive family environment and the value of unstructured exercise in weight
control in children.
a
Adapted from reference 55 with the permission of the publisher and authors. Copyright 1994
by the American Psychological Association.
225
Overweight and obesity during childhood are among the major risk
factors for the development of obesity in adulthood, since approximately 30% of obese children become obese adults (82). Childhood
obesity affects health, resulting in reduced fitness, increased blood
pressure and adverse blood lipid levels (see section 4). In addition to
the immediate health effects, obesity in adolescence increases the risk
of adult morbidity and mortality 50 years later, independently of the
effects of adult obesity (83, 84). These are powerful reasons for developing effective obesity therapies for children.
Reducing energy intake and improving dietary quality
have positive effects on body image (90). Thus, although improvement in aerobic fitness is likely to be beneficial, it should not be an
overriding concern.
Reducing time spent in sedentary behaviour
Figure 10.3
Changes in percentage overweight after 5 and 10 years of follow-up for obese
children randomly assigned to 10 interventions across four studiesa
A.
25~======~----------~
20
Non-specific
15
B. 25~==========~--------~
20
15
Non-obese parents
----
Obese parents
-20
-25
-12
-25 L_.,L_,__j__J..__J,_L_..L..__J__L,__J,_L__l__J
-12 0 12 24 36 48 60 72 84 96 108 120 132
Months
Months
c.
D. 25~========~--------~
25
Diet
20
15
...
-5, 10
~
Diet+
Lifestyle
20
Calisthenics only
-----
'#. 0
.:
Q}
-5
Ol
-10
-15
-20
-25
-12
Months
-25 L_...l.__L_----'-___J.-J...._...l.__L_----'-___J.-J...._...L_--'
-12 0 12 24 36 48 60 72 84 96 108120132
Months
WH098278
The 95% confidence interval for the total sample of children is represented by dotted lines.
The interventions all contained a diet and behavioural change component plus the specific
approaches under investigation. In the four separate studies in which Epstein et al. examined
the impact of different interventions for obesity management in overweight children, all had the
same basic diet and behavioural change intervention for 8-12 weeks and monthly review for
6-12 months. Study A compared results for children alone, children with one parent, and
nonspecific directions. Study B compared relative weight changes in children of obese and
non-obese parents. Study C examined the benefit of adding lifestyle (unstructured exercise) to
a diet programme. Study D compared the effectiveness of different forms of exercise in aiding
weight control. Both children and parents were followed up 5 and 10 years after the initial
programme. The results show excellent long-term benefits and demonstrate the value of family
support and a positive family environment and the value of unstructured exercise in weight
control in children.
a
Adapted from reference 55 with the permission of the publisher and authors. Copyright 1994
by the American Psychological Association.
225
Overweight and obesity during childhood are among the major risk
factors for the development of obesity in adulthood, since approximately 30% of obese children become obese adults (82). Childhood
obesity affects health, resulting in reduced fitness, increased blood
pressure and adverse blood lipid levels (see section 4). In addition to
the immediate health effects, obesity in adolescence increases the risk
of adult morbidity and mortality 50 years later, independently of the
effects of adult obesity (83, 84). These are powerful reasons for developing effective obesity therapies for children.
Reducing energy intake and improving dietary quality
It is generally recommended that only small reductions in energy
for active leisure pursuits can all affect a child's eating and exercise
pattern.
Strong evidence for the important role of family support in childhood
obesity and weight-management programmes comes from a number
of successful interventions. Flodmark et al. found improved weight
loss or weight maintenance in children aged 10-11 years treated
with family therapy when compared with those treated alone (97),
and Wadden et al. obtained similar results in African-American teenage girls (98). A more detailed analysis by Epstein et al. (55) suggested that weight regulation is improved if at least one parent is
treated together with the child. When the effect of targeting an overweight child alone was compared with that of targeting a child and a
parent together, the latter showed significantly less weight gain at 5
years follow-up, and were still below the relative weight (weight
corrected for height) at which they started the study at 10 years
follow-up (Fig. 10.3B). Furthermore, children of non-obese parents
were better able to obtain and maintain reductions in relative weight
(Fig. 10.3C). Epstein's findings are especially important because relative weight was maintained throughout adolescence when weight gain
can be a major problem. Other investigators have also found improved effectiveness of family-based programmes in preventing the
progression of childhood obesity.
By targeting obesity-prevention measures on the family of susceptible
children there is the added advantage that all members of the family
are likely to benefit. This helps to increase social support and to
reduce the feelings of isolation that may develop when one child is
treated separately from the rest of the family. In addition, parents
are able to exert a higher degree of external control over the child's
eating and activity patterns under these circumstances (54).
School-based programmes
The introduction of obesity-prevention programmes in schools is justified for a number of reasons. A large proportion of children attend
school (although this percentage varies from country to country) and
much of a child's eating and exercise takes place in this setting.
Schools can also assist in identifying children who may be at risk of
obesity through educational programmes and visits to the school doctor at key developmental stages. Furthermore, the start of schooling
corresponds to a period of increased risk for excessive weight gain as
children begin to become independent and vary their diet and activity
patterns in line with their new circumstances.
The results of various school-based obesity-intervention programmes
targeting high-risk children and adolescents suggest that these can
229
weaning and diet for toddlers (108). In many countries, child health
nurses already play a crucial role in monitoring the development of
infants and young children.
Special considerations in the management of childhood obesity
Risk of malnutrition. As adequate nutrition is essential for promoting healthy growth, only small reductions in overall energy intake
are recommended where such an approach is advised.
Risk of eating disorders. It is important that interventions do not
encourage the type of dietary restraint that has been linked to the
development of eating disorders and other psychological problems
(54).
Risk of isolation. It is important that overweight children are not
ostracized and made to feel any more different from their peers
than is necessary, either at home or at school (84). The message that
everyone is potentially at risk of obesity may help, but there is also
a need to generate family awareness of the need for healthier
lifestyles without suggesting that the one and only goal is to lose
weight.
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236
238
PART V
239
11.
1. General recommendations
To ensure that meaningful comparisons between populations can be
made, the classification of overweight and obesity should be standardized on an international basis, as follows:
Children. The existing WHO classification of overweight and obesity in children based on weight-for-height values of +2SD or more
of the median NCHS (National Center for Health Statistics) reference curves should be used until a new consensus is reached and a
more appropriate classification system can be recommended. Caution is needed when interpreting BMI data collected from populations with stunted children, especially in countries undergoing a
rapid nutrition transition, as the relationship of BMI to adiposity
may be altered.
2. Priority areas for further research
Priority should be given to research on:
The establishment of the most useful standard method of defining
childhood and adolescent obesity, which should then be used to
formulate new reference curves for growth and to evaluate existing
and future child and adolescent data from around the world.
The validity and tracking of simple measures of excess weight, e.g.
BMI-for-age and sex in children and adolescents from different
societies and ethnic groups.
The relationship between BMI and adiposity in stunted children.
BMI standards for the elderly (>60 years or >80 years).
International comparisons of obesity rates
3. General recommendations
Cross-sectional studies of nationally representative samples should be
regularly undertaken in all WHO regions to facilitate international
comparisons of adulthood obesity rates, to predict the magnitude of
the future obesity problem, and to monitor and evaluate the effectiveness of intervention strategies. These studies should document BMI
and waist circumference and assess progressively the variety of intervention strategies under way. In particular:
Countries in the WHO African Region, Region of the Americas,
South-East Asia and Eastern Mediterranean Regions should give
priority to regular larger-scale surveys of body weight status.
242
and obesity
Health impact of overweight and obesity in adults
1. General recommendations
The health consequences of overweight and obesity should be fully
evaluated in all parts of the world and among different ethnic groups,
as follows:
While short-duration studies are useful for identifying the major
health impact of obesity, long-term monitoring of health indicators
should be carried out to determine the full range and impact of
obesity-related illnesses, and where the outcome (e.g. cancer) is the
result of a multistage process in which obesity has an effect on
some, but not necessarily all, stages.
Standard procedures for estimating the relative risks of chronic
health problems associated with weight gain and obesity should be
established.
The prevalence and relative risks in different societies of the
chronic health problems associated with obesity should be documented.
The psychosocial impact of weight gain should be re-evaluated
using modern psychosocial techniques.
243
3. General recommendations
The health consequences associated with overweight and obesity in
childhood and adolescence should be investigated further.
5. General recommendations
The health benefits and risks of weight loss should be further investigated through well controlled studies that distinguish between unintentional weight loss (which may result from underlying disease or
smoking) and intentional weight loss.
7. General recommendations
The economic burden of overweight and obesity should be systematically evaluated in all regions of the world using a standardized methodology. For this reason:
A variety of health care systems should be evaluated so that different countries and regions can apply the analyses to their own national and regional policies.
Wherever possible, assessments should include an analysis of the
broader social and quality of life issues relating to excess weight
gain.
1. General recommendations
To enable the global problem of obesity to be tackled in a coherent
and progressive manner, it is essential that the range of factors implicated in its development, from both an individual and a population
perspective, should be fully characterized and investigated through a
coherent strategy of short- and long-term studies. In particular, the
relative importance of dietary factors and physical activity patterns
associated with a modern lifestyle should be investigated further.
246
1. General recommendations
Considerably more attention should be given to strategies aimed at
preventing weight gain and obesity, since these are likely to be more
cost-effective and have a greater positive impact on the long-term
control of body weight than those designed to deal with obesity once
it has fully developed. In particular:
Action should be taken at the following three levels to develop
effective strategies for the prevention of overweight and obesity:
2. General recommendations
Prevention of overweight and obesity should begin early in life, and
should be based on the development and maintenance of lifelong
healthy eating and physical activity patterns. In particular:
Schools should promote physical activity by incorporating a
variety of recreational activities into teaching curricula. They
247
3. General recommendations
5. General recommendations
6. General recommendations
Systematic assessment and evaluation should be a routine part of all
interventions aimed at preventing and managing overweight and
obesity. In particular:
The effectiveness of different weight-management therapies should
be evaluated in clearly defined groups of patients and in the social
context of each country.
The effectiveness of all public health programmes aimed at preventing weight gain in the population should be evaluated.
Sound experimental design and statistical principles should be used
to critically evaluate the impact of each proposed intervention.
7. Priority area for further research
Acknowledgements
The Consultation expressed deep appreciation to the International Obesity Task
Force (IOTF) chaired by Professor W.P.T. James of the Rowett Research Institute
(Aberdeen, Scotland) who was instrumental in the preparation and convening of
the Consultation. The Consultation also thanked the authors of the background
documents for the Consultation: Professor P. Bjorntorp, University of Gothenburg,
Gothenburg, Sweden; Professor G.A. Bray, Louisiana State University, Baton
Rouge, LA, USA; Or K.K. Carroll, University of Western Ontario, London, Ontario,
Canada; Or A. Chuchalin, Pulmonology Research Institute, Moscow, Russian
Federation; Or W.H. Dietz, New England Medical Center, Boston, MA, USA; Or G.E.
Ehrlich, University of Pennsylvania, Philadelphia, PA, USA; Or J.O. Hill, University
of Colorado, Denver, CO, USA; Dr F.X. Pi-Sunyer, St. Luke's Roosevelt Hospital
Center and Columbia University, New York, NY, USA; Dr W.H.M. Saris, University
of Maastricht, Maastricht, Netherlands; Or J.C. Seidell, National Institute of Public
Health and the Environment, Bilthoven, Netherlands; Professor P. Zimmet and
colleagues, International Diabetes Institute, Caulfield, Victoria, Australia.
251
The Consultation also recognized the valuable contributions made by the following
individuals who provided comments on the background documents: Professor R.L.
Atkinson, University of Wisconsin, Madison, Wl, USA; Professor H.W. Blackburn,
University of Minnesota, Minneapolis, MN, USA; Or K. Ge, Institute of Nutrition and
Food Hygiene, Chinese Academy of Preventive Medicine, Beijing, China;
Professor A. Kissebah, Medical College of Wisconsin, Milwaukee, Wl, USA; Or A.
Kurpad, St Johns Medical College, Bangalore, India; Professor J. Mann, University
of Otago, Dunedin, New Zealand; Professor K. Norum, University of Oslo, Oslo,
Norway; Or A. Prentice, Dunn Clinical Nutrition Centre, Cambridge, England;
Professor S. Rossner, Karolinska Hospital, Stockholm, Sweden; Professor P.S.
Shetty, London School of Hygiene and Tropical Medicine, London, England; Or L.
Sj6strom, Gothenburg University, Gothenburg, Sweden; Professor T.I.A. Sorensen,
Copenhagen Municipality Hospital, Copenhagen, Denmark; Or K. Steyn, Chronic
Diseases of Lifestyle, Tygerber, South Africa; Professor M. Wahlqvist, Monash
Medical Centre, Clayton, Victoria, Australia; Or R. Weinsier, University of Alabama,
Birmingham, AL, USA; Or D.F. Williamson, Centers for Disease Control and
Alabama, Birmingham, AL, USA; Or D.F. Williamson, Centers for Disease Control
and Prevention, Atlanta, GA, USA; Or R. Wing, Western Psychiatric Institute and
Clinics, Pittsburgh, PA, USA. In addition, the Consultation expressed its gratitude
to the following nongovernmental organizations, which also reviewed the
background documents and provided valuable comments: International
Association for Adolescent Health; International Diabetes Federation; International
Life Sciences Institute. Comments were also kindly provided by the South African
Society for Obesity and the World Sugar Research Organization.
Special acknowledgement was made by the Consultation to the IOTF secretariat
members Or T. Gill and Ms V. Lakin for the time they spent in preparing for the
Consultation and finalizing the report.
The Consultation expressed special appreciation to Or S. Dehler, Ms R. Imperial
and Mrs P. Robertson of the Programme of Nutrition, World Health Organization,
Geneva, Switzerland, for their efforts in preparing for the Consultation and in
revising and formatting the report, and to Mr J. Akre, also of WHO, and Mr J. Bland
for their editorial assistance.
252
Annex
Criteria for evaluating commercial institutions
involved in weight loss 1
Appropriate criteria for evaluating commercial institutions involved
in weight loss should include:
1. Identification and recording of an individual's BMI or an equivalent weight-for-height before advice is given.
2. Methods of record-keeping and analysis open to scrutiny by a
health centre if patients are to be referred from the centre. Data
on the health centre's patients should be available on request.
3. Use of an admission protocol that excludes those within the desirable weight range from a weight-reduction programme.
4. Identification of an individual or family-based approach to weight
reduction.
5. Provision of clear written as well as oral guidance on the dietary
regimen, used together with details of the expert(s) used in drawing up such guidance.
6. Specification of the methods used, if any, for encouraging physical
activity.
7. Definition of the nature of behavioural modification programmes, the frequency of visits, the use of group or individual support
and the origin of the behavioural scheme.
8. Whether food additives, drugs or other medicaments (e.g. ephedrine, caffeine homoeopathic remedies, and nutrient supplements) are used in association with therapy.
9. Methods for verifying therapeutic claims made in advertisements
or in weight-management programmes.
10. The methods chosen to alert the members' doctors to untoward
effects.
11. Any plans for coordinated activity with a health centre on weight
management.
12. The experience, training and qualifications of staff.
13. The success criteria offered to clients.
Adapted, with the permission of the publisher, from Obesity in Scotland. A rational
clinical guideline recommended for use in Scotland. Edinburgh, Scottish Intercollegiate
Guidelines Network, 1996.
253